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DR.  WILLIAM  J.  GIES  { 

to  enrich  the  library  resource 
available  to  holders 

f      GIES  FELLOWSHIP 

«2  Biological  Chemistry 


MEDICAL    DIAGNOSIS 


SPECIAL  REFERENCE  TO  PRACTICAL  MEDICINE. 


GUIDE  TO  THE  KNOWLEDGE  AND  DISCRIMINATION 
OF  DISEASES. 


BY 


J.   M.   DA   COSTA,   M.D., 


PROFESSOR   OF    PRACTICE   OF    MEDICINE   AND   OF   CLINICAL  MEDICINE   AT  THE   JEFFERSON   MEDICAL 

COLLEGE,  PHILADELPHIA  ;    PHYSICIAN  TO   THE  PENNSYLVANIA  HOSPITAL  ;   CONSULTING 

PHY'SICIAN   TO   THE   CHILDREN'S   HOSPITAL,  ETC.,  ETC. 


illustrate  foitft  dfagrabinp  flit  Mofllr. 


FIFTH   EDITION,   REVISED. 


PHILADELPHIA  : 

J.   B.   LIPPINCOTT   &   CO. 

LONDON:   16  SOUTHAMPTON   STREET,  STRAND. 

1881. 


•p/l 


Entered,  according  to  Act  of  Congress,  in  the  year  1880,  by 

J.   M.   DA    COSTA,  M.D., 
In  the  Office  of  the  Librarian  of  Congress  at  Washington. 


PREFACE  TO  THE  FIFTH  EDITION. 


This  edition  has  been  thoroughly  revised ;  condensed  in  some 
parts,  extended  in  others.  I  have  especially  aimed  at  taking  cog- 
nizance of  all  such  new  facts  of  importance  as  have  been  added  to 
Medical  Diagnosis  in  the  last  few  years;  and  this  has  necessi- 
tated almost  rewriting  some  chapters,  in  particular  those  on  the 
Nervous  System  and  on  the  Blood.  In  the  laborious  undertaking 
I  have  been  stimulated  by  the  continued  favor  the  volume  has  re- 
ceived. I  may  add  that  a  German  translation  is  now  in  process 
of  publication  by  Hirschwald,  in  Berlin.  A  number  of  new  wood- 
cuts have  been  introduced  into  the  present  edition. 

1700  "Walnut  Street,  Philadelphia, 
Dec.  1,  1880. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/medicaldiagnosis1881daco 


EXTRACT  FROM  PREFACE  TO  THE  FIRST  EDITION. 


My  chief  aim  in  writing  this  work  has  been  to  furnish  ad- 
vanced students  and  young  graduates  of  medicine  with  a  guide 
that  might  be  of  service  to  them  in  their  endeavors  to  discrimi- 
nate disease.  I  have  sought  to  offer  to  those  members  of  the  pro- 
fession who  are  about  to  enter  on  its  practical  duties  a  book  on 
Diagnosis  of  an  essentially  practical  character, — one  neither  so 
meagre  in  detail  as  to  be  next  to  useless  when  they  encounter  the 
manifold  and  varying  features  of  disease,  nor  so  overladen  with 
unnecessary  detail  as  to  be  unwieldy  and  lacking  in  precise  and 
readily-applicable  knowledge. 

In  executing  my  undertaking,  two  plans  offered  themselves  : 
either  to  describe  morbid  states  in  compliance  with  the  usual 
pathological  classification  followed  in  treatises  on  the  Practice  of 
Medicine,  or  to  group  them  according  to  their  marked  symptoms. 
The  former  plan  would  have  been  far  the  easier,  but  the  latter 
seemed  to  me  the  more  suitable  for  a  volume  of  this  kind;  and 
although  it  has  involved  much  labor,  and  has  rendered  the  task 
much  more  difficult  of  accomplishment,  its  advantages  appeared 
to  me  so  great  that  I  have  adopted  it  throughout.  That  this 
attempt  at  a  purely  clinical  classification  is  not  perfect,  I  am 
fully  aware.  But,  with  all  its  shortcomings,  I  venture  to  hope 
that  it  will  not  be  devoid  of  value  as  an  aid  in  their  studies  to 
those  for  whom  it  is  intended. 

Some  of  the  statements  made  may  appear  too  absolute,  and  as 
not  taking  sufficient  notice  of  the  many  exceptions  which  may 
arise;  but  it  was  impossible  to  avoid  this  without  very  lengthy 
discussion  :  and  even  in  the  lengthiest  discussion  all  exceptions 
and  all  possible  points  of  fallacy  would  not  have  been  mentioned; 
for  Nature  does  not  limit  herself  in  her  irregularities  any  more 
than  in  her  rules.     The  text  must,  therefore,  be  looked  upon  as 

5 


6  EXTRACT   FROM   PREFACE   TO  THE   FIRST   EDITION. 

treating  only  of  general  laws  and  of  their  most  notable  infrac- 
tions ;  in  fact,  but  as  a  series  of  etchings,  with  here  and  there  a 
prominent  figure  shaded,  but  not  as  an  attempt  to  reproduce  the 
colors  of  an  original  whose  varied  hues  could  not  be  closely  copied, 
even  by  the  hand  of  a  master. 

The  main  object  of  this  work  is,  what  its  title  implies,  the 
consideration  of  Medical  Diagnosis.  In  connection  with  this, 
however,  I  have  endeavored  to  take  cognizance  of  the  prognosis 
of  individual  affections,  and  occasionally  the  record  of  cases  has 
been  introduced  by  way  of  elucidation.  To  have  done  this  to  a 
much  greater  extent,  though  in  some  respects  desirable,  would 
have  swelled  the  work  to  an  inordinate  size. 

The  wood-cuts  employed  as  illustrations  are  all  original. 
Many  are  from  sketches,  or  at  least  are  based  on  sketches,  taken 
directly  from  cases  of  interest. 

Philadelphia,  April,  1864. 


CONTENTS. 


INTRODUCTION. 

PAGE 

General  Considerations 17 

CHAPTER  I. 

EXAMINATION  OF  PATIENTS,  AND  SOME  SYMPTOMS  OP  GENERAL  IMPORT. 

General  Considerations 27 

Position  of  the  Body 30 

General  Aspect — Expression  of  Countenance 31 

Skin 33 

Pulse. 34 

Tongue 40 

Sensations  of  Patients 43 

Temperature  of  the  Body 44 

CHAPTER   II.      ' 

DISEASES   OF   THE   BRAIN,    SPINAL   CORD,    AND   THEIR   NERVES. 

General  Considerations 52 

Deranged  Intellection 52 

Delirium '. 53 

Stupor 55 

Coma 56 

Insomnia 57 

Deranged  Sensation 57 

Hyperesthesia 57 

Anaesthesia 59 

Headache : 64 

Vertigo 66 

Derangement  of  Special  Senses , 69 

Deranged  Motion 76 

Paralysis 76 

Hemiplegia 85 

Monoplegia 92 

Paraplegia 94 

Palsies  usually  limited 104 

Local  Palsies 108 

Locomotor  Ataxia 117 

Tremor 121 

Spasms— Convulsions 123 

7 


8  CONTENTS. 

PAGE 

Deranged  Nutrition  and  Secretion 125 

Acute  Affections  of  which  Delirium  is  a  Prominent  Symptom 129 

Acute  Meningitis 129 

Tubercular  Meningitis 134 

Cerehro-spinal  Meningitis 139 

Delirium  Tremens 139 

Acute  Mania 142 

Diseases  marked  by  Sudden  Loss  of  Consciousness  and  of  Voluntary 

Motion..' 143 

Apoplexy 143 

Sun-stroke 156 

Catalepsy 158 

Diseases  marked  by  Convulsions  or  Spasms 159 

Epilepsy 159 

Chorea 164 

Hysteria 168 

Tetanus 171 

Diseases  characterized  by  Gradual   Impairment  of  the  Mental  Faculties 

with  Paralysis 175 

Chronic  Softening 175 

Tumor 179 

General  Paralysis 182 

Diseases  characterized  by  Enlargement  of  the  Head 184 

Chronic  Hydrocephalus 184 

Hypertrophy  of  the  Brain 185 

Diseases  characterized  by  Paroxysmal  Pain 186 

Neuralgia  in  General 186 

Facial  Neuralgia 188 

Hemicrania 189 

Sciatica   191 

CHAPTER   III. 

DISEASES   OF   THE    UPPER   AIR-PASSAGES. 

General  Considerations 194 

Acute  Laryngeal  Affections 202 

Acute  Laryngitis 202 

(Edema  of  the  Glottis 204 

Croup 205 

Chronic  Laryngeal  Affections 212 

Chronic  Laryngitis 212 

Diseases  of  the  Trachea 218 

CHAPTER    IV. 

DISEASES   OF   THE   CHEST. 
General  Considerations 218 


CONTENTS.  9 

SECTION    I. 

DISEASES    OF    THE    LUNGS. 

PAGE 

Different  Methods  of  Physical  Diagnosis,  and  the  Physical  Signs  of  Pul- 
monary Diseases 221 

Inspection 221 

Mensuration 222 

Palpation 227 

Percussion 227 

Auscultation 234 

Sounds  of  Eespiration  in  Health  and  in  Disease 236 

Changes  in  the  Vesicular  Murmur 237 

Bronchial  Respiration 241 

New  or  Adventitious  Sounds 243 

Auscultation  of  the  Voice 248 

Combination  of  the  Physical  Signs   and  the  Examination  of  Patients 

affected  with  Disease  of  the  Lungs 250 

Principal  Symptoms  of  Diseases  of  the  Lungs 253 

Dyspnoea 254 

Cough 258 

The  Sputa 261 

Haemoptysis 262 

Diseases  in  which  Clearness  on  Percussion  is  met  with 265 

Acute  Bronchitis 266 

Chronic  Bronchitis 270 

Emphysema 272 

Diseases  in  which  Dulness  on  Percussion  occurs 277 

Phthisis 277 

Acute  Affections  of  the  Lungs ; 301 

Acute  Phthisis 301 

Acute  Pneumonia 305 

Acute  Pleurisy ". 316 

Diseases  presenting  Dilatation  of  the  Chest,  Displacement  of  the  Liver 

and  Heart,  and  Dyspnoea 322 

Pneumothorax 323 

Chronic  Pleurisy 328 

Diseases  in  which  Extraction  of  the  Chest  occurs 335 

Chronic  Pleurisy 335 

SECTION    II. 

DISEASES    OF    THE    HEART. 

General  Considerations 339 

Examination  of  the  Heart  by  the  different  Methods  of  Physical  Diagnosis  342 

Inspection 342 

Palpation 343 

Percussion 344 

Auscultation 346 


10  CONTENTS. 

PAGE 

ral  and  Local  Symptoms  oi  D  of  the  Heart 356 

Cardiac  Dropsy 356 

Derangement  of  the  circulation 357 

Cardiac  Pain 358 

Palpitation 362 

Functional  Disorders  of  the  Eearl 363 

Disorders   characterized   by  Palpitation,  associated   or   not  with 

Change  of  Rhythm 364 

Organic  Disease-  of  the  Eearl 369 

Acute  Diseases  presenting  Pain  in  the  Cardiac  Region;  Symptoms 
of  a  Disturbed  Circulation  ;  and  a  Change  in  the  Sounds  of 

the  Heart,  or  their  Replacement  by  .Murmurs 369 

Acute  Endocarditis 370 

Acute  Pericarditis 376 

Myocarditis 385 

Cbronic  Diseases  attended  with  Increased  Extent  of  Percussion 

Dulness,  l>ut  with  Normal  or  almost  Normal  Heart-Sounds.  386 

Hypertrophy 386 

Dilatation 390 

Diseases  of  the  Heart  exhibiting  more  or  less  of  the  Signs  and 
Symptoms  of  Enlargement  of  the  Organ,  and  accompanied 

by  Endocardial  Murmurs 396 

Valvular  A  Meet  ions 396 

Displacements  of  the  Heart 410 

SECTION   III. 
Thoracic  Aneurism 411 

CHAPTER  V. 

DISEASES   OF   THE    MOUTH,  PIIARYNX,  AND    (ESOPHAGUS. 

Mouth 423 

Stomatitis...  423 

Glossitis 425 

Fauces 426 

Tonsillitis 426 

Diphtheria 428 

Chronic  Si. re  Throat 435 

Pharynx  and  (Esophagus 436 

Oesophagitis 437 

Stricture  of  Oesophagus 437 

Dilatation  of  OEsophagus 438 

CHAPTER   VI. 

DISEASES   OP   THE   ABDOMEN. 
General  Considerations 440 


CONTENTS.  11 

PAGE 

Methods  and  General  Eesults  of  Physical  Examination  of  the  Ahdomen  441 

Inspection 441 

Palpation ; 442 

Percussion 443 

Auscultation 448 


SECTION  I. 

DISEASES   OF   THE   STOMACH. 

General  Considerations 449 

Loss  of  Appetite 449 

Excessive  Acidity  of  the  Stomach 451 

Platulency 452 

Nausea  and  Vomiting 452 

Pain 460 

Diseases  of  the  Stomach  with  Pain  and  Soreness  at  the  Epigastrium,  and 

Vomiting 466 

Acute  Gastritis 466 

Chronic  Diseases  of  the  Stomach 471 

Chronic  Gastritis 471 

Gastric  Ulcer 472 

Gastric  Cancer 476 

SECTION  II. 

DISEASES   OP  THE   INTESTINES   AND   PERITONEUM. 

General  Considerations 484 

Alvine  Discharges 484 

Diseases  attended  with  Paroxysms  of  Pain  referred  chiefly  to  the  Middle 
or  Lower  Part  of  the  Abdomen,  without  marked  Tenderness, 

etc 486 

Colic 486 

Diseases  attended  with  Pain  and  marked  Tenderness  in  the  Umbilical 

Eegion  or  diffused  over  the  Abdomen 497 

Acute  Enteritis 497 

Acute  Peritonitis 500 

Chronic  Peritonitis 511 

Diseases  attended  with  Pain  and  Tenderness  in  tbe  Eight  Iliac  Eossa 513 

Affections  of  the  Caecum  and  its  Appendix 513 

Diseases   attended  with   Constipation,  and  of  which  it  is  a  Prominent 

Symptom 518 

Intestinal  Obstruction 519 

Habitual  Constipation 529 

Disorders  in  which  Morbid  Discharges  from  the  Bowels  occur 531 

Diarrhoea 532 

Dysentery 536 

Intestinal  Hemorrhage,  or  Melsena 539 

Patty  Diarrhoea 540 


12  CONTENTS. 

PAGE 

Diseases  attended  with  Vomiting  and  Purging 541 

Cholera  Infantum 541 

Cholera  Morbus 543 

Cholera 544 


SECTION   III. 

DISEASES    OF    THE    LIVER. 

General  Considerations 547 

Jaundice 548 

Acute  Diseases  of  the  Liver,  attended  generally  with  Slight  Enlargement 

of  the  Organ,  and  with  more  or  less  Jaundice 553 

Acute  Congestion 553 

Acute  Hepatitis 554 

Inflammation  of  the  Gall-Bladder  and  Gall-Ducts 559 

Acute  Diseases  characterized  by  Decrease  in  the  Size  of  the  Liver,  and 

by  Deep  Jaundice 561 

Acute  Yellow  Atrophy 561 

Chronic   Diseases    attended  with    Enlargement  of  the  Liver,  and  with 

slight  or  no  Jaundice 563 

Chronic  Congestion 563 

Chronic  Hepatitis 566 

Abscess  of  the  Liver 567 

Fatty  Liver 572 

Waxy  Liver 573 

Cancer  of  the  Liver 574 

Hydatids  of  the  Liver 582 

Chronic  Diseases  attended  with  Decreased  Size  of  the  Liver  and  with 

Abdominal  Dropsy 586 

Cirrhosis 586 

Chronic  Atrophy  of  the  Liver 592 

SECTION    IV. 

ABDOMINAL    ENLARGEMENT. 

General  Abdominal  Enlargement 593 

Ascites 593 

Chronic  Tympanites 600 

Partial  Abdominal  Enlargement 601 

Abdominal  Tumors 601 

SECTION   V. 

ABDOMINAL   PULSATION. 

Aortic  Pulsation 614 

Abdominal  Aneurism 614 


CONTENTS.  13 

CHAPTER  VII. 

ON    THE   URINE,    AND   ON   DISEASES   OP   THE  URINARY   ORGANS. 

PAGE 

Urine 619 

Color 623 

Specific  Gravity 627 

Eeaction 628 

Changes  in  the  Quantity  of  the  more  Important  Constituents 630 

Presence  of  Abnormal  Substances  in  the  Urine 645 

Sediments 668 

Urinary  Organs 670 

Diseases  of  the  Kidney  of  which  Pain  is  a  Prominent  Symptom...  670 

Nephritis 671 

Nephralgia 672 

Diseases  marked  by  an  Albuminous  Condition  of  the  Urine,  with 

more  or  less  Dropsy 676 

Acute  Bright's  Disease 677 

Chronic  Bright's  Disease 684 

Diseases  associated  with  Purulent  Urine 699 

Acute  Cystitis 699 

Chronic  Cystitis.-. 700 

Abscess  of  the  Kidney 701 

Pyelitis 704 

Disorders  in  which  a  very  large  Amount  of  Urine  is  discharged...  707 

Diabetes 707 

Chronic  Diuresis 710 

Diseases  in  which  little  or  no  Urine  is  discharged 712 

Suppression  of  Urine 712 

Pretention  of  Urine 713 

CHAPTER   VIII. 

DROPSY. 

Dropsy,  according  to  its  Seat  and  Extent 715 

Dropsy,  according  to  its  Causation 717 

Dropsy,  according  to  the  Sapidity  of  its  Development 719 

CHAPTER    IX. 

DISEASES   OP   THE   BLOOD. 

General  Considerations 721 

Anaemia 725 

Pernicious  Anaemia 730 

Leukaemia 734 

Pyaemia 738 


14  CONTENTS. 

PAGE 

Septicaemia 741 

Thrombosis  and  Embolism 742 

Scurvy 748 

Purpura 750 

CHAPTER  X. 

RHEUMATISM    AND   GOUT. 

Acute  Kheumatism 752 

Chronic  Kheumatism 757 

Gout 760 

Rheumatic  Arthritis 762 

Rickets 764 

CHAPTER    XI. 

FEVERS. 

General  Considerations 768 

Continued  Fevers 770 

Simple  Continued  Fever 770 

Catarrhal  Fever 771 

Typhoid  Fever 773 

Typhus  Fever 785 

Cerebro-spinal  Fever 794 

Relapsing  Fever 801 

Periodical  Fevers 805 

Intermittent  Fever 807 

Remittent  Fever 810 

Congestive  Fever 818 

Yellow  Fever 826 

Eruptive  Fevers 832 

Scarlet  Fever 832 

Measles 837 

Rubeola 840 

Smallpox 841 

Dengue 846 

Erysipelas 847 

CHAPTER  XII. 

DISEASES   OP   THE   SKIN. 

General  Considerations 851 

Erythematous  Diseases 853 

Papular  Diseases 855 

Vesicular  Diseases 856 

Bullous  Diseases 858 


LIST   OF   ILLUSTKATIONS.  15 

PAGE 

Pustular  Diseases 859 

Squamous  Diseases 860 

New  Growths 863 

Hypertrophies 864 

Parasitic  Diseases 865 

Altered  Gland  Secretions 868 

Nervous  Diseases 869 

CHAPTER   XIII. 

POISONS   AND   PARASITES. 

Poisons -. 870 

Acute  Poisoning 870 

Irritant  Poisons 871 

Narcotic  Poisoning 874 

Chronic  Poisoning 879 

Parasites 888 

Vegetable  Parasites 888 

Animal  Parasites 889 

Index 907 


LIST  OF  ILLUSTRATIONS. 


Pig.  1.  Sphygmograph  of  Marey 38 

2.  Ordinary  Thermometer  for  Clinical  Purposes 45 

3.  Self-registering  Thermometer 45 

4.  Seguin's  Surface  Thermometer 45 

5.  The  Thermoscope 45 

6.  The  ^Esthesiometer 62 

7.  Mathieu's  Dynamometer 80 

8.  Laryngoscopes 196 

9.  Laryngoscopic  Examination 198 

10.  Laryngeal  Image,  as  seen  in  the  Laryngoscope 199 

11.  The  Stethometer 223 

12.  The  Stetho-goniometer 223 

13.  Hutchinson's  Spirometer 224 

14.  The  Haemadynamometer 226 

15.  The  Pleximeter 228 

16.  Percussion  Hammer 229 

17.  The  Ordinary  Stethoscope 234 

18.  Hawksley's  Stethoscope 234 

19.  The  Double  Stethoscope 235 

20.  The  Differential  Stethoscope 235 

21.  Diagram  illustrative  of  the  Main  Forms  of  Feeble  Eespiration...  239 


16  LIST   OF    ILLUSTRATIONS. 

PAGE 

Fig.  22.  Diagram  illustrative  of  Rales 245 

23.  Appearance  of  the  Chest  in  Emphysema 273 

24.  Commencing  Infiltration  in  Phthisis 283 

25.  Cavities  in  the  Lung  in  Phthisis 285 

26.  Diagram  illustrative  of  Perfect  Pulmonary  Consolidation,  such 

as  occurs  in  the  Second  Stage  of  Pneumonia 307 

27.  Roughening  of  the  Pleura  from  Inflammation 317 

28.  Examination  of  Posterior  Portion  of  Chest,  a  Large  Effusion 

occupying  the  Left  Pleural  Cavity 318 

29.  Physical  Signs  of  Pneumothorax 325 

30.  Topography  of  the  Heart 340 

31.  Diagram  showing  the    Points  at    which   the  Separate  Valves 

may  he  listened  to 347 

32.  Position  of  the  Heart,  and  Distention  of  the  Pericardium  with 

Fluid,  in  Pericarditis 377 

33.  Hypertrophied  Heart,  lying  in  its  Position  in  the  Chest 388 

34.  Dilated  Heart,  the  Right  Ventricle  opened 391 

35.  Narrowing  of  the  Aortic  Orifice  by  Vegetations  springing  from 

the  Valves 401 

36.  Insufficient   Mitral   Valves   permitting   Regurgitation   of  the 

Blood 402 

37.  Sphygmogram  of  Aortic  Insufficiency 404 

38.  Sphygmogram  of  Mitral  Insufficiency 404 

39.  Results  of  Abdominal  Percussion 447 

40.  Sarcime  Ventriculi 455 

41.  Crystals  of  Uric  Acid 636 

42.  Mixed  Urates 638 

43.  Earthy  Phosphates  in  the  LTrine 640 

44.  Crystals  of  Oxalate  of  Lime 646 

45.  Pus  Corpuscles 666 

46.  Epithelial  Casts  and  Cells  from  the  Kidneys  in  a  Case  of  Acute 

Bright  s  Disease 678 

47.  Fatty  Casts  and  Epithelial  Cells  filled  with  Fat,  as  seen  in  Dis- 

charge from  a  Fatty  Kidney 692 

48.  Hyaline  or  Waxy  Casts  from  the  Urine 694 

49.  Granular  Casts,  or  Casts  covered  with  Disintegrating  Epithe- 

lium and  Granules 695 

50.  Potain's  Pipette 721 

51.  Graduated  Moist-Chamber  of  Malassez 723 

52.  Blood-Counting  with  the  Micrometer  Eyepiece 724 

53.  Temperature  Chart  in  Remittent  Fever 811 

54.  Pigment  in  the  Blood  in  Malarial  Cachexia 816 

55.  Acarus  Scabiei 866 

56.  Taenia  Solium 892 

57.  Heads  of  Taeniae 892 

58.  Trichina  in  Recent  Human  Muscle 897 

59.  Trichina  Capsule,  with  Shell-like  Calcareous  Deposits 898 

60.  Encapsuled  Chalky  Concretions  in  Muscle  due  to  Trichinae 899 

61.  Trichina  Spiralis.      Magnified  300  Diameters 901 


MEDICAL  DIAGNOSIS. 


INTRODUCTION. 

GENEEAL  CONSIDEEATIONS. 

The  study  of  any  complicated  subject  leads  of  necessity  to  its 
arrangement  into  branches.  Closely  connected  as  these  are,  and 
forming  always  parts  of  a  whole,  they  are  not  only  capable  of 
distinct  treatment,  but  frequently  become  more  intelligible  as  they 
are  so  treated.  This  is  made  very  manifest  in  investigating  dis- 
ease. The  extent  of  ground  covered  by  the  inquiry  has  rendered 
it  imperative  to  map  it  out  into  various  provinces,  which,  however 
intimately  united,  may  be  with  convenience  separately  surveyed. 
One  comprises  the  laws  and  facts  common  to  individual  affec- 
tions; in  another  are  gathered  together  all  relating  to  their  causes; 
another  embraces  the  consideration  of  their  detection  and  the  full 
recognition  of  their  nature.  It  is  the  purpose  of  these  pages  to 
examine  this  department  somewhat  minutely,  and  especially  that 
portion  of  it  coming  within  the  range  of  the  practitioner  of  med- 
icine. In  so  doing  it  will  become  apparent  how  diagnosis,  for 
such  the  distinction  of  disease  is  technically  called,  is  partly  a 
science,  partly  an  art:  a  science,  because  it  comprehensively  takes 
account  of  general  facts,  and  of  principles  based  on  those  facts; 
an  art,  because  it  demands  a  cognizance  of  the  means,  and  their 
application  to  arrive  at  the  desired  result. 

To  consider,  then,  medical  diagnosis  in  all  its  bearings,  it  will 
be  necessary  not  only  to  hold  up  to  view  the  morbid  states  met 
with  in  the  examination  of  the  sick,  but  also  to  inquire  in  what 
manner  they  may  be  most  readily  recognized  and  explored,  and 
how  their  differences  may  be  made  available  in  the  discrimination 

2  17 


18  MEDICAL    DIAGNOSIS. 

of  one  ailment  from  another.  In  a  study  of  this  kind,  an  inves- 
tigation of  symptoms  plays  unavoidably  a  prominent  part.  In 
truth,  the  detection  of  disease  is  the  product  of  close  observation 
of  symptoms,  and  of  correct  deduction  from  those  symptoms. 

The  first  requirement  therefore  for  an  accurate  diagnosis  is  to 
learn  to  recognize  morbid  signs.  But  the  art  of  observation  this 
implies  is  not  easy,  and  cannot  be  thoroughly  acquired  except  by 
practice.  No  one  aspiring  to  become  a  skilful  observer  can  trust 
exclusively  to  the  light  reflected  from  the  writings  of  others :  he 
must  carry  the  torch  in  his  own  hands,  and  himself  look  into 
every  recess.  The  knowledge  obtained  from  reading  is,  however, 
serviceable  in  this  way :  it  aids  in  overcoming  one  of  the  main 
difficulties  at  first  experienced, — to  know  where  to  look  and  what 
to  look  for.  There  are  in  almost  every  affection  some  symptoms 
which  can  hardly  escape  the  merest  beginner;  but  also  some 
which  do  not  appear  on  the  surface,  and  which  to  find  taxes  the 
skill  of  the  experienced  physician.  And  it  is  especially  in  this 
search  after  hidden  signs  that  medical  information  as  well  as  cul- 
tivated tact  is  demanded. 

Now,  to  recognize  the  manifestations  of  disease,  whether  they 
are  or  are  not  readily  perceptible,  we  have  to  employ  our  eyes  and 
ears,  our  sense  of  touch  and  of  smell.  Formerly  we  could  go  no 
further  than  these  senses  unassisted  would  carry  us.  But  science 
has  lent  its  aid,  and  furnished  means  by  the  help  of  which  we  can 
detect  clearly  what  before  we  could  not  detect  at  all,  or  that  of 
which  at  best  we  only  caught  a  glimpse.  We  now  possess  instru- 
ments by  which  we  ascertain  with  accuracy  the  size  of  organs  and 
their  play.  With  thermometers  we  tell  to  a  fraction  of  a  degree 
the  heat  of  various  parts  of  the  body.  Specific-gravity  bottles, 
and  other  measures  devised  for  the  purpose,  inform  us  of  the 
relative  gravity  of  fluids.  The  microscope  gives  at  a  glance 
insight  into  matters  which  the  naked  eye  fails  even  to  perceive. 
And  chemistry,  with  its  marvellous  teachings,  is  rendering  our 
knowledge  of  many  morbid  states  amazingly  complete.  Then 
the  sagacity  of  modern  times  has  taught  us  to  enlist  the  sense  of 
hearing,  and  demonstrated  how  a  disciplined  ear  may  detect  the 
workings  of  disease  in  cavities  into  which  the  eye  cannot  pen- 
etrate. The  effect  of  all  these  improved  methods  of  study  has 
been  to  give  an  immense  impetus  to  clinical  research,  and  thus  to 


GENERAL    CONSIDERATIONS.  19 

lead  to  the  construction  of  a  solid  groundwork  of  experience  in 
striking  contrast  with  the  looseness  and  wild  vagaries  of  former 
times.  The  advance  in  diagnosis  thus  attained  forms,  indeed,  one 
of  the  most  pleasing  portions  of  medical  history. 

When,  by  means  of  the  aided  or  unaided  senses,  the  symptoms 
of  the  malady  have  been  discovered,  the  next  step  toward  a  diag- 
nosis is  a  proper  appreciation  of  their  significance  and  of  their 
relation  toward  one  another.  Knowledge  and,  above  all,  the 
exercise  of  the  reasoning  faculties  are  now  indispensable.  The 
daily  habit  of  investigating  disease;  a  scrutinizing  study  of  the 
anatomical  lesions  ■  chemistry,  with  its  most  searching  analyses ; 
the  microscope,  with  the  wonders  it  reveals, — are  all  of  little 
use,  unless  we  have  been  taught  the  necessity  of  placing  in  con- 
nection with  one  another  the  morbid  signs  they  lay  bare,  and  of 
considering  in  individual  cases  their  respective  value.  Were  it 
otherwise,  the  science  of  diagnosis  would  be  simply  a  matter  of 
memory.  It  is,  however,  this  very  analysis  of  symptoms  and 
the  lengthy  process  of  induction  attending  it  which  make  med- 
ical diagnosis  so  difficult  and  so  unattractive  to  the  beginner. 
He  sees  that  by  reflecting  and  reasoning  on  what  are  frequently 
but  indirect  manifestations  he  must  find  the  seat  and  nature 
of  disorders  hidden  from  his  view.  Nor  is  it  reasoning  on  the 
ascertained  facts  alone  that  is  required :  the  premises  may  be  but 
probabilities ;  for,  in  truth,  diagnosis  deals  at  times  with  the 
logic  of  probabilities  as  much  as  with  the  logic  of  patent  facts. 

Now,  we  are  greatly  aided  in  appreciating  the  import  of  morbid 
signs,  and  in  interpreting  them  correctly,  by  already  existing 
knowledge.  We  look  to  landmarks  which  our  predecessors  have 
erected,  and  the  gradually  accumulated  science  of  semeiology, 
rightly  employed,  furnishes  the  clue  to  the  discovery  of  the  dis- 
ease. Thus  the  stores  which  medicine  has  laboriously  collected 
during  centuries  can  be  used  with  advantage  by  all,  and  exist  for 
the  good  of  all. 

But  an  acquaintance  with  semeiology  is  far  from  being  the  sole 
guide  to  diagnosis,  nor  does  it  at  once  help  to  a  recognition  of  the 
malady.  There  are  few  symptoms  in  themselves  distinctive ;  and 
often  a  symptom  may  be  due  to  one  of  several  causes.  Semeiology 
informs  us  of  these  different  causes ;  but  to  find  out  the  precise 
meaning  of  the  abnormal  manifestation  in  an  individual  case,  we 


20  MEDICAL    DIAGNOSIS. 

have  to  draw  our  inference  from  all  the  signs  encountered  ;  to 
compare  them  with  one  another;  to  seek  out  those  that  are  in  the 
background.  We  are  thus  arriving,  step  by  step,  at  the  explana- 
tion of  the  morbid  appearances,  the  starting-point  in  deduction 
always  being  what  is  known  of  the  affection  the  presence  of  which 
is  suspected,  and  the  symptoms  of  which  we  are  contrasting  with 
those  before  us.  For  the  conclusion  to  be  valid  and  exact,  it  is  of 
course  requisite  that  each  part  of  the  testimony  have  the  proper 
position  assigned  to  it.  In  reasoning  correctly  on  symptoms,  the 
same  laws  apply  as  in  reasoning  correctly  on  any  other  class  of 
phenomena  :  the  facts  have  to  be  sifted  and  weighed,  not  merely 
indiscriminately  collected.  And  while  the  intellectual  act  is  being 
performed,  much  collateral  evidence  is  to  be  sought  before  a  final 
judgment  is  given  ;  especially  is  it  necessary  to  view  the  symp- 
toms with  constant  reference  to  the  age,  sex,  and  habits  of  the 
patient,  and  to  the  circumstances  amid  which  the  disorder  develops 
itself. 

To  accomplish  all  this  effectually,  the  physician  has  need  of 
much  and  varied  knowledge.  He  must  be  master  of  something 
more  than  of  the  information  supplied  to  him  by  semeiology.  He 
must  be  an  anatomist  to  pronounce  with  certainty  on  the  seat 
of  the  malady ;  a  physiologist  to  appreciate  the  aberration  of 
functions.  Above  all,  he  must  be  a  pathologist  in  the  full  sense 
of  the  term  :  he  must  understand  the  antagonism  between  dis- 
eases; the  frequency  with  which  they  coexist;  the  influence  of 
remedial  agents  on  them  ;  and  be  cognizant  of  their  natural  history 
and  of  the  general  laws  governing  them, — for  how  else  can  he 
form  an  estimate  of  morbid  action  while  in  progress?  Then  it 
is  desirable  that  he  should  be  aware  of  what  are  their  current 
divisions  and  classifications.  From  what  has  already  been  repre- 
sented, it  is  evident  that  he  must  also  be  a  correct  reasoner  ;  for 
even  a  good  observer  will,  by  bad  reasoning,  arrive  at  a  faulty 
diagnosis;  just  as  sometimes  a  bad  observer  may,  by  the  same 
process,  blunder  into  the  truth.  There  is,  indeed,  no  end  to  the 
extent  of  knowledge  which  may  be  brought  to  bear  in  working 
out  a  conclusion  regarding  the  character  and  seat  of  a  malady. 
The  habit  of  observation  once  acquired,  information  of  the  most 
varied  kind  will,  by  an  accurate  reasoner,  be  made  tributary  to 
the  completeness  of  the  diagnosis.     Every  fresh  acquirement  tends 


GENERAL    CONSIDERATIONS.  21 

to  enlarge  our  powers  of  insight.  Just  as  in  nature,  the  higher 
we  ascend,  the  more  fully  lies  the  view  before  us. 

Having  thus  indicated  the  elements  of  a  precise  and  thorough 
diagnosis,  we  may  next  inquire  in  what  way  this  is  most  speedily 
and  conveniently  arrived  at  when  at  the  bedside.  The  main  facts 
of  the  case  on  which  the  deductions  are  to  be  based  are  of  course 
first  elicited ;  and  we  shall  presently  see  how  this  may  be  most 
effectually  done.  We  lay  hold  of  the  main  facts,  and  especially 
of  those  which  are  the  most  direct  signs  of  the  morbid  action. 
They  are  coupled  together,  and  the  inquiry  is  started  as  to  what 
organ  they  indicate  as  the  seat  of  the  malady.  This  often  has  been 
already  determined  by  the  very  method  of  the  examination;  and 
we  therefore  proceed  at  once  to  investigate  the  precise  nature  of 
the  disorder  by  analyzing  the  symptoms  and  the  previous  history. 
Sometimes,  however,  the  site  of  the  disease  does  not  admit  of 
being  definitely  fixed  upon,  or  we  cau  only  in  a  general  manner 
decide  upon  the  function  impaired.  Again,  as  in  idiopathic 
fevers,  we  may  find  no  signs  of  local  disease, — merely  those  of  a 
general  disturbance.  In  any  of  these  instances  clinical  experience 
steps  in  to  explain  the  phenomena  as  far  as  possible,  and  to  in- 
form us  in  what  affections  they  occur.  It  may  be  only  in  one; 
then  the  desired  goal  is  at  once  attained.  But,  as  above  stated, 
there  are  few  signs  in  themselves  pathognomonic.  It  is  therefore 
to  be  ascertained  which  one  of  the  disorders  is  before  us  that 
special  pathology  teaches  may  yield  the  symptoms  encountered. 
One  of  these  is  taken  up.  Its  symptoms  are  placed  side  by  side 
with  those  present.  They  accord  in  some  respects,  but  not  in  all. 
Moreover,  in  searching  for  some  of  the  phenomena  which  the 
supposed  malady  gives  rise  to,  these  are  not  found.  The  view  is 
abandoned,  and  another  taken  up.  It  agrees  in  all  particulars. 
The  diagnosis  is  made.  Yet,  when  the  diagnosis  is  thus  arrived 
at,  we  have,  before  it  can  be  considered  as  complete  and  be  acted 
upon,  still  to  determine  whether  or  not  any  other  morbid  state 
exists,  and  to  take  into  account  the  patient's  general  condition 
and  his  individuality. 

To  cite  a  case  in  illustration.  A  person  consults  us  for  a  cough 
brought  on  by  exposure.  He  has  been  sick  for  four  or  five  days, 
having  been  previously  in  good  health.  We  notice,  on  examining 
him,  that  his  breathing  is  hurried,  and  that  he  has  fever;  the 


22  MEDICAL    DIAGNOSIS. 

lower  portion  of  one  side  of  the  chest  is  dull  on  percussion,  and 
the  respiration  there  is  wanting;  the  action  and  sounds  of  the 
heart  are  normal.  The  facts  point  to  the  lung  or  its  covering  as 
the  seat  of  the  disorder.  We  know,  furthermore,  from  the  his- 
tory and  the  febrile  symptoms,  that  we  have  to  deal  with  an  acute 
affection.  What  are  the  acute  pulmonary  affections  ?  Acute  bron- 
chitis; acute  phthisis;  acute  pleurisy;  acute  pneumonia.  In  all 
occur  fever,  cough,  and  impaired  breathing.  Is  it  acute  pneu- 
monia? No;  for  notwithstanding  there  is  in  this  complaint, 
in  addition  to  the  general  symptoms  mentioned,  dulness  on  per- 
cussion, such  as  we  have  here,  the  dulness  is  associated  with  a 
blowing  respiration ;  whereas  in  the  case  before  us  no  respiration  is 
heard.  Let  us  look  at  the  sputum,  and  see  if  it  is  tenacious  and 
rusty-colored.  It  is  not;  it  is  thin  and  frothy.  But  acute  pleu- 
risy may  explain  all  the  signs.  The  patient,  too,  when  questioned, 
states  that  he  had  at  the  onset  a  sharp  pain  in  his  side;  and  this, 
we  are  aware,  takes  place  in  pleurisy.  The  vocal  vibrations,  like- 
wise, are  noticed  to  be  absent  on  the  affected  side  of  the  chest, 
which,  when  measured,  is  found  to  be  enlarged.  This  corresponds 
in  all  points  with  what  happens  in  pleurisy  in  the  stage  of  effu- 
sion. The  disease  is,  therefore,  acute  pleurisy  in  the  stage  of 
effusion.  We  finish  the  diagnosis  by  ascertaining  the  existence 
or  non-existence  of  other  maladies,  and  by  taking  note  of  the 
severity  of  the  complaint;  that  it  has  occurred  in  a  young  and 
robust  person  of  good  habits ;  and  that  the  symptomatic  fever  is 
very  active. 

This  process  of  arriving  at  an  opinion  is  the  simplest.  It  is 
one  in  which  the  investigation  of  the  case  is  to  some  extent  car- 
ried on  while  the  deductions  are  being  made.  And  it  is  astonish- 
ing how  rapidly  it  may  be  performed  by  habit.  The  mind  works 
unconsciously,  and  a  decision  is,  to  all  appearance,  formed  intui- 
tively, which  surprises  the  inexperienced  by  its  readiness  and  pre- 
cision. This  method  aims,  so  far  as  the  symptoms  permit,  at  a 
direct  diagnosis.  But,  in  truth,  it  is  often  what  is  called  differen- 
tial: that  is,  it  takes  cognizance  of  and  dwells  on  the  essential 
signs  by  which  one  disease  can  be  discriminated  from  another 
resembling  it. 

Sometimes,  instead  of  attaining  the  desired  result  in  the  manner 
proposed,  we  are  obliged  to  judge  of  the  nature  of  the  malady 


GENERAL    CONSIDERATIONS.  23 

entirely  by  finding  out  what  it  is  not.  The  various  diseases  ca- 
pable of  producing  all,  or  even  some,  of  the  striking  symptoms 
observed,  are  enumerated.  They  are  one  by  one  considered  and 
set  aside,  until  by  this  process  of  pure  exclusion  the  mischief  is. 
brought  to  light.  Thus,  to  use  again  the  example  just  given,  we 
should  have  to  assign  reasons  why  the  disease  is  neither  acute 
pneumonia,  nor  bronchitis,  nor  acute  phthisis,  and  in  this  way 
determine  it  to  be  acute  pleurisy.  But  to  prove  what  a  thing  is 
by  proving  all  that  it  is  not,  is  a  very  tedious  process,  and  we 
must  be  quite  certain  that  really  all  morbid  states  which  may  give 
rise  to  the  symptoms  encountered  are  thought  of  and  inquired  into; 
otherwise  our  conclusion  may  be  fallacious,  though  reasoned  out 
in  the  most  logical  manner.  Moreover,  our  knowledge  of  many 
pathological  conditions  is  so  imperfect  that  we  are  not  fully  cog- 
nizant of,  or  able  at  once  to  discern,  the  more  characteristic 
signs;  nor  can  the  symptoms  be  taken  hold  of  and  arranged  in 
such  a  way  as  shall  permit  us  to  make  nice  distinctions  without 
a  lengthy  and  laborious  plan  of  procedure.  Owing  to  these  draw- 
backs, diagnosis  by  exclusion  is  not,  on  ordinary  occasions,  much 
employed,  nor,  indeed,  is  it  to  be  recommended.  Yet  in  difficult 
and  obscure  cases,  where  the  accustomed  pathway  is  blocked  up, 
it  may  enable  us  to  pass  by  obstacles  otherwise  insurmountable. 

But  can  we  by  this  or  by  any  other  road  always  reach  a  cer- 
tain diagnosis?  We  cannot,  and  for  several  reasons.  The  patient 
may  deceive  us,  wilfully  or  unintentionally.  It  may  be  necessary, 
for  the  confirmation  of  the  opinion  formed,  to  obtain  an  accurate 
history  of  the  case,  and  circumstances  may  render  this  impossible. 
The  disorder  may  be  so  rare  that  its  symptoms  are  not  understood. 
There  may  be  several  lesions  present,  the  signs  of  one  masking  or 
neutralizing  the  signs  of  the  other. 

The  first  of  the  causes  mentioned  is  a  source  of  error  difficult 
to  guard  against.  To  escape  punishment,  to  avoid  disagreeable 
duty,  to  excite  compassion,  to  obtain  a  compliance  with  unreason- 
able wishes,  or  sometimes  from  the  mere  love  of  deception,  symp- 
toms may  be  stated  to  exist  which  do  not  exist,  or  may  be  imitated 
and  artificially  produced.  Persons  who  thus  feign  disease  are 
numerous.  They  are  found  in  all  occupations  and  in  all  classes 
of  society.  They  abound  in  the  army  and  navy.  Hysterical 
women  and  hypochondriacs  help  to  swell  the  list.     These,  indeed, 


24  MEDICAL    DIAGNOSIS. 

suffer  mostly  some  inconvenience,  but  exaggerate  it  immensely, 
and,  by  deceiving  themselves,  end  by  deceiving,  unless  he  be  on 
his  guard,  their  physician.  On  the  other  hand,  disease  actually  in 
•progress  may  be  carefully  concealed  from  motives  of  delicacy  or 
from  fear  of  the  consequences. 

An  incorrect  diagnosis  from  want  of  a  proper  history  does  not, 
on  the  whole,  occur  often.  Patients  are  generally  very  willing  to 
give  a  full  account  of  themselves  and  of  their  distresses.  Some- 
times, however,  the  reverse  happens.  Pain  or  mental  anxiety  and 
sorrow  may  be  wearing  the  body  out  while  the  sufferer  obstinately 
persists  in  hiding  the  cause  of  his  waning  health.  We  meet  also 
with  individuals  so  stupid  that  the  most  elaborate  cross-examina- 
tion fails  to  elicit  anything  like  a  connected  history.  Again,  we 
may  be  unable  to  do  so  from  the  patient  having  lost  the  power  of 
speech.  A  man  is  brought  into  a  hospital  unconscious.  It  is  of 
the  utmost  importance  to  know  how  long  he  has  been  in  this  state, 
and  what  were  his  prior  symptoms  ;  unless  some  friend  can  supply 
the  information,  the  most  valuable  diagnostic  data  are  wanting. 

In  the  rarity  of  a  disease  we  have  a  serious  drawback  to  its 
recognition.  This  may  occasion  au  error  of  diaguosis  in  a,  two- 
fold manner.  The  more  distinctive  symptoms  may  be  so  little 
understood,  and  the  prominent  features  so  nearly  identical  with 
those  of  a  malady  with  the  manifestations  of  which  we  are  well 
acquainted,  that  a  conclusion  of  the  presence  of  the  latter  forces 
itself  almost  immediately  on  the  mind.  Or,  the  disorder  may 
give  rise  to  phenomena  wholly  unknown,  nothing  but  the  autopsy 
revealing  their  true  meaning.  Every  physician  encounters  such 
cases.  It  is  true  that  the  progress  of  science  and  the  aggregation 
of  clinical  facts  are  from  year  to  year  bringing  them  into  a  nar- 
rower circle.  Yet,  are  there  not  still  diseases,  nay,  groups  of  dis- 
eases,  that  have  eluded  discovery  to  the  manifold  means  of  research 
of  the  present  day,  as  they  have  to  the  accumulated  experience  of 
the  past '.' 

But  the  most  serious  obstacle  to  a  precise  diagnosis  lies  in  the 
fact  that  frequently  several  lesions  coexist.  Disease  is  a  very 
complex  state,  and  when  one  portion  of  the  economy  gets  out  of 
order,  another  is  apt  to  follow.  Plow  close,  for  example,  the  con- 
nection between  affections  of  the  heart  and  of  the  kidney  !  Here 
it  is  easy  to  arrive  at  a  conclusion,  since  we  have  the  means  of 


GENERAL    CONSIDERATIONS.  25 

judging  accurately  of  the  condition  of  both  organs.  But  there 
are  instances  in  which  it  is  very  difficult,  especially  when  a  part 
contiguous  to  one  chronically  affected  is  attacked  with  acute  dis- 
ease. A  person  applies  for  relief,  presenting  all  the  symptoms  of 
a  severe  local  peritonitis.  The  inflammation  spreads ;  death  re- 
sults. The  exciting  cause  of  the  inflammation  is  discovered  to  be 
a  structural  alteration  of  one  of  the  abdominal  viscera,  the  signs 
of  which  were  completely  merged  in  the  more  marked  signs  of 
the  recent  inflammation.  And  this  disguisement  is  effected  not 
only  by  the  supervention  of  another  and  more  acute  complaint, 
but  also  sometimes  by  the  prominence  of  those  remote  sympa- 
thetic derangements  which  an  affection  of  any  viscus  may  produce. 
Thus,  the  disturbed  action  of  the  heart  in  dyspeptic  persons  throws 
at  times  the  symptoms  of  the  gastric  malady  into  the  shade.  Yet 
it  must  be  admitted  that  errors  of  diagnosis  from  this  source  are 
not  apt  to  occur  to  the  careful  practitioner.  A  thorough  exami- 
nation of  the  case  is  a  safeguard  against  them. 

These,  then,  are  the  various  .causes  which  render  a  diagnosis 
uncertain,  or  wholly  unattainable.  Let  us  add  to  them  one  that 
does  so  temporarily.  There  are  disorders  the  early  manifestations 
of  which  are  so  much  alike  that  it  is  next  to  impossible  to  tell  with 
which  of  several  we  have  to  deal.  In  fevers  this  often  happens. 
Here,  however,  a  few  days,  or  even  less  time,  will  almost  always 
solve  the  difficulty.  But  not  so  in  other  diseases.  It  is  only  after 
a  much  longer  period,  and  by  careful  watching  of  the  patient,  that 
the  appearance  or  disappearance  of  a  striking  symptom,  or  the 
greater  prominence  a  hitherto  indistinct  sign  assumes,  inclines  the 
scales  toward  one  or  the  other  of  the  affections  between  which 
judgment  has  been  kept  in  suspense. 

In  some  such  instances,  the  treatment  becomes  the  touchstone 
of  the  diagnosis.  Now  it  may  be  asked,  Does  this  demonstrate 
that  the  diagnosis  of  a  case  is  not  necessary  for  its  treatment? 
Not  at  all.  It  simply  proves  that  we  are  sometimes  obliged  to 
aim  at  removing  symptoms  without  understanding  their  source. 
But  it  does  not  prove  that  if  we  understood  their  source  we  should 
not  be  better  able  to  remove  the  symptoms.  The  physician  who 
undertakes  to  relieve  disease  simply  by  attempting  to  allay  its 
symptoms,  regardless  of  their  cause,  and  without  understanding 
their  true  relation  and  significance,  is  groping  in  the  dark.     His 


26  MEDICAL    DIAGNOSIS. 

treatment  is  vacillating;  drag  replaces  drug;  alleviation  is  taken 
for  a  cure;  and  the  experience  obtained  is  utterly  untrustworthy. 
One  great  advantage,  indeed,  of  attending  carefully  to  diagnosis 
is,  that  it  enables  us  to  use  remedies  knowingly,  and  with  decision ; 
to  appreciate  what  they  are  effecting;  to  abstain  from  such  as  must 
be  injurious.  There  is  less  needless  meddling,  more  calmness; 
the  treatment  rises  above  the  consideration  of  the  moment,  and 
takes  into  account  what  is  for  the  patient's  ultimate  good.  It  is 
sometimes  urged  that  the  accurate  detection  of  disease  makes  timid 
practitioners,  and  deprives  them  of  confidence  in  medicines.  More 
just  is  it  to  say  that  it  shows  how  wide  is  the  chasm  between  our 
acquaintance  with  morbid  conditions  and  with  remedies ;  how  far, 
unfortunately,  our  skill  to  detect  disease  outruns  our  power  to 
cure  it. 

There  is  undoubtedly,  however,  a  danger  which  may  arise  from 
paying  very  minute  attention  to  diagnosis.  The  study  of  it  is  so 
interesting,  and  capable  of  being  conducted  so  entirely  without 
reference  to  other  points,  and  especially  to  the  treatment  of  the 
complaint,  that  some  minds  are  carried  away,  and,  lost  in  the  pur- 
suit of  diagnostic  knowledge,  forget  for  what  purposes  chiefly  that 
knowledge  is  profitable.  Its  main  use  is  to  enable  us  to  foretell 
the  course  and  probable  issue  of  a  malady,  and  to  frame,  with 
understanding,  plans  to  relieve  the  sufferings  and  disorders  of 
those  who  have  intrusted  their  health  and  their  lives  into  our 
hands.  Xor  ought  we  ever  to  be  unmindful  how  important  it  is, 
in  basing  the  management  of  a  disease  on  its  diagnosis,  to  found 
that  diagnosis  on  a  general  survey  of  all  the  circumstances ;  how 
necessary  not  to  assign  prominence  to  minor  points;  and  how  the 
extent  of  the  affection,  the  circumstances  under  which  it  has  oc- 
curred, the  sympathetic  disturbances  produced,  and  the  vital  state 
of  the  patient,  belong,  rightly  considered,  quite  as  much  to  the 
diagnosis  as  the  recognition  of  the  precise  seat  and  exact  ana- 
tomical character  of  the  malady,  and  are,  in  truth,  frequently  its 
more  important  part. 


CHAPTEE   I. 

THE  EXAMINATION  OF  PATIENTS,  SYMPTOMS  OP  GENEEAL 
IMPOET,  AND  SOME  OP  THE  INSTEUMENTS  EMPLOYED 
IN    THE   DIAGNOSIS   OP   DISEASE. 

To  elicit  the  facts  of  a  case  by  a  careful  examination  is,  as  lias 
been  stated,  the  first  requisite  for  diagnosis.  To  conduct,  however, 
a  clinical  inquiry  with  precision  and  facility,  requires  continual 
practice,  and  is  rendered  easier  by  following  some  well-digested 
plan.  The  advantage  of  adopting  a  method  is  clearly  seen,  if  the 
attempts  of  a  beginner  be  watched.  He  wanders  in  his  search 
from  one  part  of  the  body  to  another,  attracted  by  different  symp- 
toms in  turn ;  pointless  question  succeeds  to  pointless  question ; 
and  a  conclusion,  almost  certainly  erroneous,  is  finally  jumped  at, 
or  an  acknowledgment  made  of  inability  to  arrive  at  any. 

Now,  there  are  several  ways  which  have  been  proposed  to  over- 
come this  embarrassment.  One  of  the  principal  consists  in  first 
questioning  the  patient  with  regard  to  his  history.  His  age;  his 
occupation ;  the  diseases  from  his  childhood  up ;  his  habits ;  his 
constitution;  the  affections  hereditary  in  his  family, — are  all 
minutely  inquired  into.  After  this  the  origin  and  progress  of  the 
existing  disorder  are  traced,  and  the  remedies  ascertained  that 
.have  been  used  against  it.  The  present  condition  is  then  ex- 
plored; each  organ  or  each  system  being  in  turn  interrogated. 
The  investigation  is  now  regarded  as  complete ;  the  facts  are  con- 
sidered, and  the  diagnosis,  prognosis,  and  treatment  determined. 
This  method  of  examining  is  termed  the  synthetical  or  historical. 
Another,  the  analytical,  reverses  the  order.  The  present  con- 
dition is  first  ascertained,  and  subsequently  the  patient's  history  or 
anamnesis.  Both  of  these  courses  have  something  to  recommend 
them,  and  some  strong  objections.  The  synthetical  method  is  the 
more  purely  scientific ;  but  it  is  too  full,  and  calls  for  too  much 
labor,  to  meet  the  requirements  of  ordinary  professional  life.     It  is 

27 


23  MEDICAL    DIAGNOSIS. 

much  better  adapted  for  recording  cases  in  the  pursuit  simply  of 
pathological  knowledge,  and  decidedly  the  best  where  the  history 
is  obscure  and  the  symptoms  are  ill  defined.  The  plan  which  I 
habitually  prefer  is  to  take  a  general  survey  of  the  history  and  of 
the  prominent  symptoms,  and,  having  thus  obtained  some  clue  to 
the  part  most  likely  to  be  affected,  to  explore  that  with  care.  For 
instance :  we  are  brought  to  the  bedside  of  a  patient  for  the  first 
time;  we  inquire  how  long  he  has  been  sick;  how  that  sickness 
began;  in  what  way  he  is  now  troubled, — whether  he  has  pain, 
or  what  is  the  main  source  of  his  annoyance.  While  questioning 
him,  we  are  scanning  his  appearance,  the  position  of  the  body, 
his  movements,  his  manner  of  breathing.  The  hand  is  applied 
to  the  skin ;  the  pulse  is  felt.  Partly  from  this  examination  and 
partly  from  the  history,  some  organ  is  fixed  upon  to  be  specially 
investigated  :  say  pain  in  the  epigastric  region  and  vomiting  are 
complained  of, — our  attention  is  directed  to  the  stomach.  We 
explore  this  organ,  its  physical  state  and  its  functions.  Then  we 
look  to  the  parts  that  are  anatomically  or  physiologically  most 
nearly  related  to  it,  which  are,  in  the  case  cited,  the  intestines  and 
liver.  The  examination  is  completed  by  taking  heed  of  the  con- 
dition of  other  portions  of  the  body ;  by  reviewing  the  history  of 
the  case;  and  by  endeavoring  to  elicit  fully  such  points  as  bear 
upon  the  diagnosis,  which  the  mind,  consciously  or  unconsciously, 
has  already  begun  to  frame.  Then  a  balance  between  the  symp- 
toms is  struck,  the  diagnosis  is  recast,  modified,  or  extended,  and 
the  treatment  is  decided  upon. 

There  is  some  repetition  in  this  plan,  but  it  is  the  one  which 
appears  practically  the  most  suitable.  It  has  the  advantage  of 
bringing  together  the  marked  features  of  a  case,  and  especially 
those  most  clearly  indicative  of  the  general  or  vital  condition. 
But  whatever  scheme  be  chosen,  it  should,  for  us  to  become  pro- 
ficient in  it,  be  as  constantly  and  closely  adhered  to  as  the  varying 
circumstances  of  disease  will  permit.  Yet  thoroughly  to  acquire 
the  habit  of  examining  with  accuracy  and  care,  and  also  to  obtain 
the  full  fruits  of  experience,  it  is  indispensable  to  keep  written 
records.  This,  too,  should,  so  far  as  possible,  be  done  according 
to  a  uniform  design,  since  it  both  prevents  us  from  overlooking 
important  symptoms  and  enables  cases  to  be  more  readily  com- 
pared.    I  subjoin  a  schedule  which  I  have  used  for  some  time, 


EXAMINATION    OF    PATIENTS,    ETC.  29 

and  which  is  based,  as  closely  as  practicable,  on  the  plan  of  ex- 
amination just  mentioned. 

Date  of  Examination;  jSTaine ;  Age;  Color;  Place  of  Birth; 
Present  Abode ;  Occupation  or  social  state ;  In  females,  whether 
married  or  not,  number  of  children,  and  date  of  last  confinement. 

History. 

1.  History  antecedent  to  present  disease:  Constitution  and 

General  Health  —  Hereditary  predisposition  —  Pre- 
vious Diseases  or  Injuries — Habits  and  mode  of  life ; 
hygienic  influences  to  which  exposed,  etc. 

2.  History  of  present  disease :  Its  supposed  exciting  cause 

— Date  of  seizure — Mode  of  invasion ;    subsequent 
symptoms   in   order   of   succession — Previous   treat- 
ment. 
Present  Condition  of  Patient. 
1.    General  Symptoms : 

-n    .i.       f  in  bed — mode  of  Iving  ; 
Position  <  „  ,    ,  "     ° ' 


out  of  bed — movements; 

Aspect  /<*  body; 
I  of  counte 


of  countenance; 
Skin  ; 
Pulse ; 

Respiration — as  to  frequency,  etc. ; 
Tongue ; 

f  appetite  ; 
General  state  of  Digestion  J  thirst ; 

(^  condition  of  bowels ; 
General  state  of  Urinary  Secretion  ; 
Sensations  of  patient :  pain,  etc. 
2.  Examination  of  special  regions  or  functions,  beginning 
with  the  one  presumably  the  most  affected. 
Diagnosis. 
Treatment. 

Remarks. 
The  history  is  here  placed  first ;  then  the  symptoms  of  general 
import,  such  as  those  furnished  by  the  pulse  and  tongue,  are  made 
to  precede  the  examination  of  special  regions.  These  general 
symptoms  are  of  great  value  in  the  recognition  of  disease,  and  of 
yet  greater  value  in  determining  its  treatment.     They  are  some- 


30  MEDICAL    DIAGNOSIS. 

thing  more  than  the  mere  physical  signs  of  textural  affections; 
they  indicate  vital  conditions,  and  partly  from  their  value,  and 
partly  from  their  not  being  linked  to  disease  of  any  organ  in 
particular,  they  demand  a  separate  and  detailed  consideration. 

Position  of  the  Body. — By  noting  whether  the  patient  is  in 
bed  or  out  of  bed, — how  he  lies,  or  how  he  walks, — a  general  idea 
may  be  formed  as  to  the  acuteness  of  an  attack,  the  impairment 
of  strength  it  has  produced,  and  sometimes  even  as  to  its  nature. 
Let  a  person  who  has  been  actively  attending  to  his  usual  occu- 
pation be  suddenly  confined  to  his  bed,  and  the  inference  that  the 
disease,  if  not  dangerous,  is  at  all  events  a  severe  and  acute  one, 
will  be  commonly  correct;  certainly  so,  if  no  mishap  to  the 
organs  of  locomotion  have  necessitated  a  resort  to  the  recumbent 
position.  When  the  patient  lies  for  a  long  time  on  his  back,  it  is 
generally  from  exhaustion,  or  from  paralysis,  or  it  is  owing  to 
the  pain  which  pressure  or  motion  of  any  kind  occasions.  Such 
is  the  cause  of  the  dorsal  decubitus  in  peritonitis,  and  in  rheuma- 
tism. Lying  fixedly  upon  one  side  may  be  looked  upon  as  an 
indication  that  the  action  of  the  lung  of  this  side  is  impeded, 
and  that  the  respiration  has  to  be  carried  on  with  the  other. 
There  are  exceptions  to  this  rule,  but  not  enough  to  destroy  its 
value.  The  patient  may  be  confined  to  bed,  yet  unable  to  lie 
down  in  it,  on  account  of  the  distress  in  breathing  to  which  the 
recumbent  posture  gives  rise:  he  leans  forward,  or  sits  erect. 
This  necessity  of  breathing  in  the  upright  position,  or  "  orthop- 
ncea,"  is  a  form  of  dyspnoea  encountered  especially  in  diseases  of 
the  heart,  or  where  fluid  is  effused  into  the  air-cells  or  into  both 
pleural  cavities. 

If  a  person  is  able  to  be  about,  his  posture  and  movements  be- 
come important  manifestations  of  his  condition.  The  young  and 
the  strong  walk  erectly,  quickly,  and  firmly  ;  the  aged  and  the 
weak,  stoopingly,  slowly,  and  with  difficulty.  In  diseases  of  the 
spine  the  body  is  bent :  so,  too,  in  affections  of  the  larger  joints 
of  the  lower  extremities. 

When,  after  a  fever,  or  any  other  prostrating  malady,  the 
patient  leaves  his  bed,  he  totters,  moves  slowly,  and  is  soon 
obliged  to  rest:  returning  strength  brings  with  it  a  quicker  and 
steadier  gait.  In  some  diseases  of  the  brain  the  movements  are 
staggering ;  in  one-sided  palsy  they  are  uncertain,  and  the  affected 


EXAMINATION    OF    PATIENTS,    ETC.  31 

side  lags,  or  its  motions,  if  it  can  be  moved  at  all,  are  laborious. 
Excessive  and  uncontrollable  movements  are  observed  in  mania 
and  in  chorea;  trembling  motions  in  states  of  extreme  debility, 
in  shaking  palsies,  and  in  the  delirium  of  drunkards. 

General  Aspect — Expression  of  Countenance. — The 
eye  notices  rapidly  whether  the  body  is  bulky  or  wasted,  and 
whether  the  surface  is  discolored  or  otherwise  changed.  The 
indications  afforded  by  the  latter  appearance  will  be  more  conve- 
niently spoken  of  in  connection  with  the  morbid  states  of  the  skin ; 
but  to  those  furnished  by  the  former  a  few  lines  may  be  here  de- 
voted. A  bulky  aspect  of  the  whole  body  is  the  result  of  corpu- 
lency, or  arises  from  universal  anasarca.  In  some  acute  diseases, 
too,  a  general  tumefaction  may  take  place, — for  example,  in  the 
exanthemata.  A  partial  increase,  or  a  swelling,  arises  from  the 
local  extravasation  of  fluid  or  air  into  the  cellular  tissues.  If  air, 
the  tissues  crepitate  under  the  finger;  if  fluid,  the  skin  pits  under 
pressure.  A  swelling  may,  further,  proceed  from  an  inflammatory 
thickening,  or  from  a  tumor  or  any  morbid  growth. 

A  diminution  in  bulk  is  a  more  frequent  and  a  more  striking 
symptom  than  an  augmentation.  It  may  take  place  very  rapidly, 
as  witnessed  in  Asiatic  cholera.  More  generally  the  wasting  is 
gradual,  and  is  a  sure  indication  of  the  nutrition  of  the  body  not 
being  properly  carried  on.  It  occurs  in  the  course  of  protracted 
fevers,  and  in  most  chronic  diseases.  In  dangerous  and  slowly 
fatal  maladies,  and  in  those  attended  with  constant  discharges, — 
for  instance,  in  chronic  diarrhoea, — the  loss  of  flesh  reaches  its 
highest  point. 

Emaciation  is  most  readily  recognized  in  the  face.  It  gives 
rise  to  that  significant  change  in  the  features  which  at  once  reveals 
the  existence  of  disease.  Not  that  emaciation  is  the  only  striking 
alteration  observable  in  the  countenance  when  health  has  failed. 
There  may  be  a  pallor,  sallowness,  a  livid  hue  of  the  lips,  a  puffy 
appearance  of  the  eyelids,  a  flush  on  the  cheeks.  Now,  these 
changes  in  the  features,  added  to  the  expression  which  pain  or 
special  trains  of  thought  produce,  make  up  that  peculiar  physi- 
ognomy of  disease  so  pregnant  with  meaning.  But  I  shall  not 
attempt  to  describe  in  detail  the  cast  or  the  play  of  features  in  the 
sick;  the  shades  of  expression  are  so  numerous  that  they  baffle 
description,  and  are  to  be  learned  only  by  continuous  bedside 


32  MEDICAL    DIAGNOSIS. 

experience.     I  shall  merely  set  down  a  few  broad  facts  which  this 
experience  teaches. 

Among  the  countenances  most  frequently  met  with,  is  that  of 
apathy  and  stupor.  The  eye  is  dull  and  listless;  the  face  pale, 
or  flushed  with  fever.  This  look  is  very  common  in  fevers  of  a 
low  type,  and  is  often  combined  with  blackish  accumulations  on 
the  lips,  gums,  and  teeth. 

Unnatural  fulness  and  congestion  of  the  features  are  some- 
times observed  in  enlargements  of  the  heart,  and  oftener  still  in 
habitual  drunkards.  The  same  aspect  is  seen  in  apoplexy  and  in 
typhus  fever. 

A  pinched  expression  is  found  when  there  is  intense  anxiety  or 
pain,  or  a  wasting  malady  attended  with  constant  suffering.  It  is 
specially  observed  in  acute  peritoneal  inflammation.  When  very 
marked,  and  accompanied  by  change  of  hue,  it  is  the  face  which 
Hippocrates  has  so  graphically  described.  In  the  great  master's 
own  words,  "a  sharp  nose,  hollow  eyes,  collapsed  temples;  the 
ears  cold,  contracted,  and  their  lobes  turned  out;  the  skin  about 
the  forehead  being  rough,  distended,  and  parched  ;  the  color  of  the 
whole  face  being  green,  black,  livid,  or  lead-colored."  This  is  the 
physiognomy  of  approaching  death,  and  generally  its  speedy  fore- 
runner, except  in  those  cases  in  which  the  expression  proceeds 
from  want  of  food,  from  protracted  vigils,  or  from  excessive  dis- 
charge from  the  bowels. 

The  face  of  shock,  with  its  great  pallor,  its  anxious  or  fright- 
ened look,  and  its  fixed  or  oscillating  eye,  often  with  a  contracting 
pupil,  is  a  face  seen  after  severe  injuries,  and  as  such  familiar  to 
the  surgeon.  But  in  many  of  its  main  traits  it  may  be  also  met 
with  in  diseases  that  make  a  sudden  and  overwhelming  impression 
on  the  nervous  system;  for  instance,  it  is  at  times  encountered  in 
cerebro-spinal  fever  and  in  cholera. 

An  aspect  serious  and  dull  on  one  side,  while  the  other  side  is 
in  full  play,  is  witnessed  in  some  instances  of  hemiplegia,  or  in 
paralysis  of  the  facial  branch  of  the  seventh  nerve.  The  differ- 
ence in  the  cast  of  the  features  may  escape  observation  when  the 
face  is  in  repose,  but  as  soon  as  an  attempt  is  made  to  laugh,  it 
shows  itself  plainly. 

Independently  of  these  lineaments  Avhich  may  be  said  to  be 
common  to  several  diseases,  wc  read  frequently  in  the  countenance 


EXAMINATION    OF    PATIENTS,    ETC.  33 

the  signs  of  special  disorders.  A  dusky  flush  on  the  face,  if  as- 
sociated with  rapid  breathing,  is  almost  a  certain  indication  of 
inflammation  of  the  lung.  Puffiness  of  the  eyelids  in  a  pallid 
person  is  very  apt  to  be  expressive  of  Bright's  disease.  A  bluish 
color  of  the  lips  shows  plainly  that  the  venous  circulation  is  inter- 
fered with,  or  that  the  blood  is  but  imperfectly  aerated.  Then 
there  is  the  straw-colored,  anaemic  hue  of  malignant  disease;  the 
jaundiced,  melancholy  look  of  an  hepatic  affection  ;  the  downcast 
expression  and  mobility  of  the  features  in  hysteria;  the  thickened 
upper  lip,  delicate  skin,  and  fair  complexion  of  scrofula ;  the  sal- 
low countenance  and  peculiar  notched  teeth  which  indicate  inherited 
syphilis,  and  the  various  traits  which  tend  to  mark  not  only  the 
special  diathesis,  but  also  the  peculiar  temperament  with  the  mor- 
bid tendencies  that  belong  to  it.  But  this  is  not  a  subject  to  be 
pursued  here  any  further;  it  has  merely  been  touched  upon  to 
exhibit  the  diagnostic  importance  of  a  study  of  the  countenance.* 

Skin. — By  the  state  of  the  skin  we  can,  to  a  great  extent, 
judge  of  the  activity  of  the  circulation  and  of  the  character  of 
the  blood.  Moreover,  it  is  a  fair  index  of  the  secretions,  and  of 
the  condition  of  the  system  at  large.  In  fevers,  along  with  the 
quickened  circulation,  the  temperature  of  the  skin  is  increased; 
the  attending  dryness  is  produced  by  defective  perspiration.  Cold- 
ness of  the  surface  indicates  a  weakened  capillary  circulation,  and 
is  met  with  at  the  invasion  of  acute  diseases,  and  when  the  nervous 
power  is  under  the  sway  of  some  highly  deleterious  influence.  If 
heat  of  surface  succeed  a  cold  skin,  we  know  that  reaction  has 
taken  place,  that  the  circulation  has  again  become  active.  Pro- 
tracted coldness,  whether  attended  with  dryness  or  with  clamminess, 
is  of  evil  augury :  it  implies  a  seriously  diminished  vital  force. 

The  cutaneous  covering  is  pale  whenever  the  blood  is  poor  and 
watery.     If  it  be  seriously  vitiated  and  deprived  of  its  fibrin,  as 


*  For  fuller  information  on  the  Physiognomy  of  Disease,  and  especially  on 
the  physiognomical  value  in  diagnosis  of  special  features,  as  the  jaws,  palate, 
teeth,  ears,  hair,  the  reader  is  referred  to  Laycock's  Lectures,  Med.  Times 
and  Gazette,  vol.  i.,  1862;  also  to  a  paper,  ib.,  Sept.  1867.  The  individual 
muscles  concerned  in  physiognomical  expression  have  been  made  the  subject 
of  careful  study  by  Duchenne  in  "  Physiologie  des  Mouvements,"  Paris,  1867. 
Much  suggestive  information  is  also  contained  in  Darwin's  well-known  volume 
"  On  the  Expression  of  the  Emotions  in  Man  and  Animals,"  1872. 

3 


31  MEDICAL    DIAGNOSIS. 

in  putrid  fevers,  black  spots  are  seen,  due  to  extravasation.  Oft- 
times  the  surface  is  overspread  with  eruptions,  some  of  which  bear 
a  close  relation  to  disorders  of  internal  organs,  while  others  are 
connected  with  febrile  or  general  maladies;  and  others,  again,  are 
owing  to  a  disease  of  the  texture  itself. 

Tension  of  the  skin  is  met  with  in  acute  affections  accompanied 
by  active  excitement.  In  wasting  and  prostrating  ailments,  on 
the  other  hand,  the  skin  feels  very  relaxed  and  soft;  and  in  those 
producing  rapid  emaciation,  it  is  inelastic  and  lies  in  folds. 

Pulse. — The  study  of  the  pulse,  elevated  into  a  science  by 
Galen  and  his  disciples,  has  come  down  to  us  with  the  sanction  of 
centuries;  and  to  feel  the  beat  at  the  wrist  is  still,  in  the  opinion 
of  many,  as  indispensable  to  the  understanding  of  a  case  as  it  was 
thought  to  be  by  the  Arabs  and  in  the  Middle  Ages.  Yet  the 
advance  of  science  has  shaken  the  belief  in  the  paramount  impor- 
tance of  the  pulse.  It  has  shown  that,  although  a  most  valuable 
means  of  information,  it  is  not  exclusively  to  be  relied  upon,  and 
has  proved  the  many  divisions  and  refinements  of  the  physicians 
of  by-gone  days — who  endeavored  by  the  pulse  to  judge  of  every 
conceivable  morbid  condition — to  be  practically  useless.  Indeed, 
were  even  all  their  distinctions  founded  in  fact,  we  have  now 
better  ways  of  judging  of  lesions  than  by  feeling  the  radial  artery. 
The  same  may  be  said  of  the  prognostic  indications  drawn  from 
the  pulse.  It  affords  us  in  this  respect  much  instruction  ;  but  any 
attempt  to  revive  the  various  critical  pulses,  as  taught  by  Solano 
or  Bordeu,  would  be  received  with  the  same  derision  as  we  do  the 
pretensions  of  our  Chinese  brethren  to  distinguish  diseases  by 
feeling  the  pulse  of  the  right  or  the  left  side,  or  to  determine  by 
the  pulse  the  sex  of  the  child  in  a  pregnant  woman. 

The  pulse  enlightens  us  on  the  action  of  the  heart,  and  on  some- 
thing more, — on  the  state  of  the  artery  itself  and  of  the  blood. 
In  a  healthy  adult  a  beat  of  some  resistance  is  felt,  recurring  from 
sixty-five  to  seventy-five  times  in  a  minute.  It  becomes  slower 
with  advancing  years,  though  it  may  rise  in  the  very  aged.  The 
pulse  of  infancy  is  from  one  hundred  and  ten  to  one  hundred  and 
twenty;  and  of  a  child  three  years  old,  from  ninety  to  ninety-five. 
Warmth  quickens  the  pulse;  so  do  rapid  breathing,  forced  expira- 
tion, and  the  process  of  digestion.  In  the  recumbent  position  and 
during  sleep  it  falls. 


EXAMINATION    OF    PATIENTS,    ETC.  35 

At  the  bedside  we  study  in  the  pulse  its  frequency,  its  rhythm, 
its  volume  and  strength,  and  its  resistance. 

Increased  frequency  of  the  pulse  denotes  increased  frequency 
of  the  heart's  action,  and  arises  from  any  cause  which  excites  the 
heart.  Hence  exercise,  rapid  breathing,  mental  emotion,  or  rest- 
lessness will  occasion  the  number  of  beats  to  exceed  the  average 
of  health  as  readily  as  fevers  or  acute  inflammatory  diseases.  In 
great  debility,  too,  the  pulse  rises;  and  the  more  depressed  the 
vital  condition,  the  higher  the  pulse  becomes.  The  heart  may 
thus  quicken  from  so  many  and  such  varied  causes  acting  tempo- 
rarily or  permanently,  that  increased  frequency  of  pulse,  taken  by 
itself,  has  no  significant  diagnostic  meaning. 

A  sloio  pulse,  too,  happens  in  many  different  states,^in  cold, 
exposure  to  wet,  in  icterus.  It  is  also  produced  by  an  intense  and 
prostrating  shock,  or  is  found  coexisting  with  pressure  on  the  brain. 
In  some  persons  the  pulse  is  naturally  very  slow. 

The  rhythm  of  the  pulse  is  often  perverted.  Instead  of  the 
beats  following  one  another  in  regular  succession,  they  are  unequal, 
or  one  or  two  intermit.  An  irregular  pulse  occurs  from  digestive 
troubles,  from  gout,  or  from  debility  and  nervous  exhaustion ;  but 
it  is  also  frequently  the  indication  of  a  cerebral  or  cardiac  lesion. 
It  is  sometimes  a  difficult  beat  to  count ;  and  we  must  be  careful 
not  to  regard  at  once  a  pulse  as  irregular  because  it  appears  to 
intermit.  The  seeming  irregularity  may  be  caused  by  the  fingers 
slipping  from  the  artery,  which  they  are  very  apt  to  do  after  they 
have  been  on  the  vessel  for  some  time. 

The  volume  and  strength  of  the  pulse  are  of  much  more  im- 
portance than  either  its  rhythm  or  its  frequency.  Volume  and 
strength  are  often  associated,  and  are  much  alike;  but  they  are 
not  identical.  When  the  beat  of  the  artery  is  large,  we  call  it 
a  full  pulse.  This  is  owing  to  the  distention  of  the  vessel  with 
blood, — its  complete  expansion  with  every  beat  of  the  heart.  A 
full  pulse  is,  therefore,  the  pulse  of  plethora;  the  pulse  of  the 
young  and  robust  in  health,  or  in  inflammatory  diseases ;  the  pulse 
in  the  early  stages  of  fevers,  or  in  obstruction  of  the  capillaries. 
It  is  usually  a  pulse  of  power,  just  as  its  opposite,  a  small  pulse, 
is  usually  the  pulse  of  debility.  Yet  a  full  pulse  may  be  pro- 
duced by  the  distention  of  an  artery  which  has  lost  its  tone,  and 
which  the  finger  easily  compresses.     Such  a  pulse,  the  "gaseous 


36  MEDICAL    DIAGNOSIS. 

pulse,"  denotes  exhaustion,  and  proves  that  a  full  pulse  and  a 
strong  pulse  are  not  always  synonymous.  Indeed,  into  the  idea 
of  strength  something  more  than  mere  fulness  enters.  A  strong 
pulse  is  a  natural  pulse  heightened  in  all  its  characters.  It  has 
more  fulness,  but,  in  addition,  more  impulse,  and  less  compressi- 
bility, than  an  ordinary  pulse.  A  strong  pulse,  therefore,  indicates 
activity  of  the  contraction  of  the  heart,  and  a  normal,  perhaps 
increased,  tonicity  of  the  arterial  coats.  It  is  found  in  active  in- 
flammations ;  also  in  hypertrophy  of  the  heart.  Its  opposite,  a 
weak  pulse,  betokens  want  of  force,  often  want  of  healthy  blood. 
It  is  generally  small  as  well  as  weak.  Yet  as  the  full  pulse  is 
not  always  strong,  neither  is  the  small  pulse  always  weak.  The 
small,  choked  pulse  of  peritoneal  inflammation  may  be  fine  and 
wiry;  but  who  would  call  it  a  weak  pulse? 

The  residance  or  tension  of  the  pulse  is  another  valuable  guide 
in  the  appreciation  of  morbid  action.  Is  the  pulse  hard  and  resist- 
ing? is  it  soft  and  compressible?  are  questions  on  the  solution  of 
which  the  application  of  remedies  may  hang.  A  hard,  tense  pulse 
denotes  increased  contractility  of  the  arteries,  and  high-wrought 
power.  Be  the  beat  full  or  small,  slow  or  frequent,  it  tells  us  that 
the  blood  is  being  driven  with  force  along  the  arterial  system. 
But  it  also  tells  us  that  the  irritation  has  implicated  the  coats 
of  the  arteries  themselves,  as  their  extreme  resistance  to  the  finger 
plainly  shows.  A  tense  pulse  is  met  with  in  active,  violent  inflam- 
mations, and  sometimes,  though  not  often,  in  states  of  extreme  and 
continued  excitement  without  inflammation.  It  is  almost  needless 
to  add  that  changes  in  the  coats  of  the  arteries  may  also  be  a  cause 
of  a  hard  and  resistant  beat.  Where  no  local  alterations  are  present, 
and  where  no  acute  symptoms  explain  the  sympathetic  disturbance 
of  the  heart  and  arterial  system,  a  tense  pulse  will  be  commonly 
found  associated  with  hypertrophy  of  the  left  ventricle. 

The  opposite  of  the  hard  pulse  is  the  soft  or  compressible  pulse. 
This  implies  deficient  impulsion,  and  loss  of  tone  in  the  vessel; 
it  is  the  pulse  of  low  fevers  and  of  debility.  But  it  is  also,  when 
following  a  tense  state  of  the  artery,  the  pulse  which  denotes 
returning  health,  and  imminent  danger  passed. 

Such  are  the  meanings  attached  to  the  various  characters  of  the 
pulse.  Yet  they  do  not  often  present  themselves  thus  isolated. 
The  following  are  usually  combined,  and  bear  this  explanation : 


EXAMINATION     OF    PATIENTS,    ETC.  37 

A  hard,  full,  frequent  pulse  occurs  in  active  inflammations,  and 
in  most  of  the  acute  diseases  of  robust  persons. 

A  hard  pulse,  full  or  small,  bounding  or  not,  if  unconnected 
with  acute  symptoms,  leads  to  the  suspicion  of  cardiac  disease,  or 
of  an  affection  of  the  artery  itself. 

A  tense,  contracted,  and  frequent  pulse  is  met  with  in  a  large 
group  of  inflammations  below  the  diaphragm,  as  in  enteritis,  peri- 
tonitis, gastritis. 

A  frequent  pulse,  full  or  small,  but  rarely  tense,  is  the  pulse  of 
most  idiopathic  fevers. 

A  very  frequent  pulse,  but  very  feeble  and  compressible,  is  the 
pulse  of  marked  debility,  of  prostration,  of  collapse. 

A  pulse  frequent,  and  changeable  in  its  rhythm,  is  produced, 
for  the  most  part,  by  disease  either  of  the  heart  or  of  the  brain. 

The  appreciation  of  these  different  kinds  of  pulses  requires 
considerable  practice.  But  even  this  scarcely  teaches  us  to  esti- 
mate the  exact  degree  of  the  alteration  of  the  beat,  certainly  not 
with  sufficient  distinctness  to  convey  to  others  an  accurate  idea, 
or  even  to  be  able  ourselves  to  compare  one  observation  with  an- 
other. To  attain  these  desirable  results,  physiologists  have  sought 
for  instruments  by  means  of  which  the  pulse  might  be  examined 
with  precision,  its  finer  shades  of  difference  recognized,  and  its 
movements  recorded.  The  best  instrument  as  yet  invented  is  the 
sphygmograph  of  Marey,*  which  registers  with  correctness  not 
only  the  frequency  and  regularity  but  also  the  form  of  pulsation, 
and  may  be  applied  almost  as  readily  to  the  study  of  the  cardiac 
impulse  and  of  pulsatile  tumors  as  toward  gaining  a  knowledge 
of  the  pulse-wave.  Slight  irregularities  which  wholly  escape  the 
finger  may  be,  through  its  aid,  discerned  with  facility,  and  we  can 
tell  at  once  in  how  far  these  irregularities  belong  to  one  beat  or  to 
a  succession  of  beats.  Double  beats,  too,  not  appreciable  to  the 
hand,  are  easily  detected.  Indeed,  one  of  the  most  valuable  re- 
sults arrived  at  by  the  sphygmograph  concerns  the  type  of  pulse 
in  which  a  double  beat  is  perceived  with  each  contraction  of  the 
heart.  This,  the  "  dicrotic"  pulse,  or  the  pulsus  biferiens  of  the 
older  authors,  is  most  commonly  met  with  in  fevers  of  a  typhoid 
form,  and  preceding  or  during  the  continuance  of  hemorrhages. 

*  Physiologie  medicale  de  la  Circulation  du  Sang,  Paris,  1863. 


38 


MEDICAL    DIAGNOSIS. 


Yet  the  phenomenon  of  dierotism  may  be  stated  to  be  really  a 
physiological  one,  since  the  sphygmograph  proves  it  to  exist  in 
almost  every  person.  The  rebound  is  chiefly  due  to  the  oscilla- 
tion of  the  column  of  blood  in  the  arteries,  and  is  very  much 


Fig.  1. 


The  sphygmograph  attached  to  the  wrist.     Its  tracings  are  seen  by  the  white  lines  on  the  black 

background. 

influenced  by  their  elasticity.  It  is  rarely  sufficient  to  be  deter- 
mined by  the  touch,  except  when  the  arterial  tension  or  con- 
tractility is  lessened  and  the  elasticity  of  the  tubes  increased,  as 
happens  in  the  disorders  in  which  the  dicrotic  pulse  is  encoun- 
tered. In  old  persons,  in  whom  the  coats  of  the  arteries  are 
inelastic,  dierotism  is  but  feebly  marked.  A  rapid  circulation 
renders  the  pulse  more  obviously  dicrotic.  The  rebound  may 
occur  during  the  systole  or  the  diastole  of  the  vessel ;  and  instead 
of  one,  there  may  be  four  or  five  of  the  secondary  pulsations. 

When  we  apply  the  sphygmograph  for  clinical  purposes,  we 
study  chiefly  in  its  tracings  the  line  of  ascent,  the  summit,  and 
the  line  of  descent.  Each  pulsation  is  composed  of  these  three 
parts.  The  line  of  ascent,  the  upstroke,  tells  us  the  manner  in 
which  the  blood  enters  the  vessels.  The  more  rapid  the  flow,  and 
the  more  quickly  the  artery  distends,  the  more  vertical  the  line. 
The  force,  too,  is  indicated  by  this  line,  or  rather  by  its  height; 
though  here  we  find  that  the  strength  of  the  ventricular  contrac- 
tion  is  far  from  being  the  only  cause  influencing  the  amplitude 
of  the  tracing.  Indeed,  as  we  may  note  in  old  persons,  a  large 
volume  of  the  artery  gives  very  considerable  height  to  the  lines 
of  ascent ;  so  does  a  long  interval  between  the  pulsations,  or  the 
obstruction  of  the  vessel  below  the  point  where  the  observation  is 
made.  A  state  of  feeble  tension  in  the  capillary  system,  further, 
has  the  same  effect;  whereas  when  the  passage  in  the  ultimate 
ramification  of  the  vascular  system  is  difficult,  the  lever  descends 


EXAMINATION    OF    PATIENTS,    ETC.  39 

slowly  by  a  line  convex  upward,  and  is  soon  again  raised  by  the 
next  pulsation.  The  line  joining  the  summit  of  a  series  of  pul- 
sations, or  the  maxima  of  tension,  is  generally  a  straight  line ;  a 
similar  imaginary  line  connecting  the  bases,  or  the  minima,  is  apt 
to  run  parallel  to  it ;  but  irregularity  of  pulsation  leads  to  irregu- 
lar lines,  and  the  lower  line  may  be  irregular  while  the  upper  is 
straight. 

The  summit  of  the  pulsation  informs  us  of  the  time  during 
which  the  entrance  of  blood  balances  the  onward  flow.  The 
summit  may  be  a  horizontal  line  of  some  length,  and  an  extended 
plateau  of  the  kind  is  apt  to  be  met  with  in  induration  or  ossifica- 
tion of  the  arteries.  In  some  instances  we  find  a  little  hooked 
point  preceding  the  usually  transverse  mark  of  the  summit.  This 
occurs  by  the  rapid  movement  of  the  lever,  and  is  a  sign  of 
regurgitation  through  the  aortic  valves. 

The  line  of  descent  follows  the  closure  of  the  semilunar  valves. 
It  is  sometimes  purely  oblique,  and  the  more  rapidly  the  pressure 
is  lessened  in  the  arterial  system,  the  more  oblique  is  the  line. 
It  often  shows  a  series  of  undulations,  which  give  rise  to  the 
dicrotism  in  the  pulse  which  has  been  above  mentioned. 

These  points  must  all  be  attended  to  in  examining  sphygmo- 
graphic  tracings;  but,  unfortunately,  the  mode  of  adjusting  the 
instrument,  and  of  proportioning  the  pressure  of  the  spring,  has 
something  to  do  with  the  kind  of  delineation  obtained.  To  secure 
greater  accuracy,  Sanderson  fixed  the  centre  button  at  a  definite 
pressure,  thus  insuring  an  arrangement  very  useful  for  purposes  of 
comparison ;  and  Mahomed*  has  added  several  serviceable  con- 
trivances, one  of  the  chief  of  which  is  the  causing  of  the  amount 
of  pressure  employed  to  be  accurately  registered  upon  a  dial. 
Still  another  modification,  which,  however,  really  makes  use  of  a 
different  principle,  the  displacing  power  of  the  artery  rather  than 
its  lifting  power,  has  been  made  by  Holden.f  The  movement 
thus  obtained  is  from  side  to  side.  The  most  recent  sphygmo- 
graph, and  one  making  extremely  fine  tracings,  is  the  instrument 
invented  by  Poncl.J     A  rubber  diaphragm  takes  the  place  of  the 

*  Medical  Times  and  Gazette,  Jan.  1872. 
f  The  Sphygmograph,  Phila.,  1874. 

X  Pamphlet  on  Improved  Sphygmograph.      See  also  Med.  and  Surg.  Re- 
porter, June,  1878;  and  Archives  of  Medicine,  vol.  i.,  New  York,  1879. 


40  MEDICAL    DIAGNOSIS. 

spring  of  other  sphygmographs,  and  is  fixed  to  the  artery  by 
means  of  a  holder,  or  there  is  a  metallic  button  with  a  small  ver- 
tical lever  attached,  which  is  kept  in  contact  with  the  artery,  and 
is  employed  when  the  amount  of  pressure  is  to  be  estimated.  A 
delicate  needle  makes  the  tracing. 

To  show  the  tracing  distinctly,  smoked  glass  or  mica,  or  paper 
smoked  over  a  lamp  or  by  burning  camphor,  has  been  of  late 
much  used.  Manifold,  too,  have  been  the  suggestions  to  obtain 
the  steadiest  application  of  the  instrument  to  the  forearm  and  the 
greatest  development  of  the  trace.  Lorain*  has  proved  that 
raising  the  arm  to  a  vertical  position  gives  a  much  more  ample 
trace.  Still,  with  all  the  careful  work  on  the  subject,  and  all  the 
perfection  of  the  instrument,  its  precise  value  for  clinical  research 
is  yet  to  be  determined.  After  using  it  considerably,  I  think  it 
much  more  likely  to  be  of  avail  in  investigations  on  the  exact 
action  of  medicines  than  in  aiding  us  very  materially  either  in 
questions  of  diagnosis  or  in  decisions  on  treatment.  At  all  events, 
I  still  do  not  think  it  has  been  shown  that  it  supersedes  the  older 
and  more  usual  means  of  research. 

Tongue. — When  a  patient  is  told  to  put  out  his  tongue,  it  is 
not  because  the  physician  thinks  it  obligatory  to  see  whether  or 
not  this  organ  is  the  seat  of  disease,  but  because  experience  has 
taught  him  that  the  tongue  is  a  mirror,  more  or  less  perfect,  of  the 
condition  of  the  digestive  functions,  and  that  it  reflects  the  com- 
plexion of  the  nervous  power  and  of  the  blood,  and  the  state  of 
the  secretions.  To  judge  of  these  varied  circumstances,  we  have 
to  examine  the  tongue  in  regard  to  its  movements,  its  volume,  its 
dryness  or  its  humidity,  its  color,  and  its  coating. 

The  movements  of  the  tongue  are  impeded  and  tremulous  in 
all  conditions  of  the  system  attended  with  exhaustion.  It  is  pro- 
truded slowly  and  with  difficulty  in  fevers  of  a  low  type,  and  in 
nervous  disorders  which  are  accompanied  by  marked  debility. 
The  action  of  the  muscles  is  seriously  impaired  in  paralysis.  In 
hemiplegia  one  side  is  crippled,  and  the  tongue  turns  toward  one 
of  the  corners  of  the  mouth.  When  imperfect  articulation  is 
associated  with  difficulty  in  moving  the  organ,  it  commonly 
announces  a  serious  cerebral  lesion. 

*  Le  Pouls,  Paris,  1870. 


EXAHIXATIOX    OF     PATIENTS,    ETC.  41 

The  volume  of  the  tongue  is  changed  by  its  own  diseases ;  more 
rarely  by  the  condition  of  the  system  at  large,  or  by  disturbances 
of  the  abdominal  viscera.  Yet  a  swollen  or  a  broad  and  flabby 
tongue,  on  the  sides  of  which  the  teeth  leave  their  marks,  is  some- 
times found  in  chronic  ailments  of  the  digestive  organs,  and  as 
the  result  of  the  action  of  mercury,  and  of  certain  poisons.  It  is 
further  observed  in  some  affections  of  the  brain,  or  as  a  conse- 
quence of  the  disturbed  circulation  attending  diseases  of  the  heart, 
and  in  distempers,  like  the  plague,  typhus,  or  scurvy,  in  which 
the  blood  is  much  altered. 

Dryness  of  the  tongue  indicates  deficient  secretion.  In  acute 
visceral  inflammations,  and  still  more  frequently  in  the  exan- 
themata and  in  typhoid  fever,  the  tongue  is  dry  ;  it  may  be  so  dry 
as  to  cause  the  papillae  to  become  prominent  and  the  whole  organ 
to  appear  roughened.  This  condition  is  one  which,  in  acute  dis- 
eases, is  always  to  be  dreaded,  especially  if  the  tongue  be,  in 
addition,  of  a  dark  color,  or  furred  or  fissured ;  for  it  is  then  a 
proof  not  only  of  arrested  secretions,  but  also  of  depraved  blood 
and  of  ebbing  life-force.  Yet  a  fissured  tongue  is  not,  by  itself, 
indicative  of  great  and  imminent  danger;  it  may  occur  in  chronic 
affections  of  the  liver,  or  in  chronic  inflammation  of  the  intes- 
tines; and  in  some  persons  it  is  congenital.  The  opposite  of 
dryness,  humidity,  is,  unless  excessive,  a  favorable  sign.  It  is 
extremely  so  if  it  succeed  to  dryness,  because  it  is  a  proof  that 
the  secretions  are  being  re-established. 

The  color  of  the  tongue  is  subject  to  many  variations.  It  is 
remarkably  pale  whenever  the  blood  is  watery  and  deficient  in  red 
globules.  It  is  exceedingly  red  and  shining  in  the  exanthemata, 
especially  in  scarlet  fever.  The  tongue  is  also  very  red  if  inflam- 
mation have  attacked  its  substance,  or  the  fauces,  or  the  pharynx. 
It  is  bluish  and  livid  when  there  is  an  obstruction  to  the  flow 
of  the  venous  blood  or  deficient  aeration,  as  in  some  structural 
diseases  of  the  heart  and  in  dangerous  cases  of  bronchitis  or 
pneumonia. 

As  important  as  the  color  of  the  organ  are  the  color  and  form 
of  its  coating.  In  health  the  tongue  has  hardly  a  discernible 
lining;  disease  quickly  gives  it  one.  In  inflammation  of  the 
respiratory  textures,  at  the  commencement  of  fevers,  in  disorders 
of  large  portions  of  the  abdominal  mucous  tract,  the  epithelium 


42  MEDICAL    DIAGNOSIS. 

accumulates,  and  the  tongue  has  a  loaded,  whitish  appearance. 
The  coat  is  apt  to  be  yellowish  in  disturbances  of  the  liver,  and 
of  a  brown  or  very  dark  line  when  the  blood  is  contaminated. 
But  we  must  be  sure,  in  drawing  our  inferences,  that  the  abnormal 
aspect  is  not  due  to  the  food  partaken  of  or  to  medicine.  Its 
color  is  also  modified  by  the  character  of  the  occupation.  Thus, 
as  Chambers  tells  us,  there  is  a  curious,  smooth,  orange-tinted 
coating  on  the  tongues  of  tea-tasters.  A  local  cause  sometimes 
gives  rise  to  a  thick,  opaque  coat.  For  instance,  decayed  teeth 
may  produce  a  yellow  sheathing  on  one  side.  Affections  of  the 
fauces  also  occasion  a  deep-yellow  hue.  Again,  some  persons, 
even  in  health,  wake  up  every  morning  with  their  tongues  covered 
at  the  back  with  a  heavy  coating,  which  wears  off  during  the 
day. 

In  some  diseases  the  epithelium,  which  is  either  formed  in  ex- 
cessive quantities  or  not  thrown  off,  collects  between  the  papilla?, 
leaving  them  uncovered  and  prominent.  This  is  especially  noticed 
in  scrofulous  children.  When  the  epithelium  is  sticky  and  ad- 
herent, it  winds  itself  chiefly  around  the  filiform  papilla?,  giving 
to  the  surface  of  the  organ  a  furred  appearance.  Although  this 
kind  of  tongue,  as  almost  every  other  variety,  is  met  with  now 
and  then  in  persons  who  are  not  ill,  yet  it  may  generally  be 
looked  upon  as  denoting  serious  difficulty.  It  occurs  sometimes 
in  chronic  diseases  of  the  abdominal  viscera,  but  much  oftener  in 
grave  acute  maladies.  The  tongue,  on  the  other  hand,  may  be 
denuded,  or  imperfectly  covered  with  epithelium.  AVe  meet  with 
this  in  certain  instances  of  scurvy,  or  in  cases  of  chronic  diarrhoea 
and  dysentery  with  great  prostration,  or  attending  cachexias,  as 
the  malarial.  Again,  a  denuded  tongue  is  common  in  scarlet 
fever,  and  not  infrequent  in  typhoid  fever. 

To  sum  up,  before  leaving  the  subject,  the  manifestations 
afforded  by  the  tongue  which  are  indicative  of  danger.  They  are, 
tremulous  action;  dryness;  a  livid  color;  a  very  red,  shining,  or 
raw  aspect ;  a  marked  fur,  or  a  heavy  coating  of  a  dark  or  black 
hue.  Any  change  from  these  to  a  more  natural  look  bears  a 
favorable  interpretation. 

The  state  of  the  digestion  and  the  character  of  the  discharges 
have  so  close  a  connection  with  the  nutrition  of  the  body  that 
they  become  important  general  symptoms.     But,  for  the  sake  of 


EXAMINATION    OF    PATIENTS,    ETC.  43 

convenience,  their  value  will  be  inquired  into  while  discussing 
the  diseases  in  the  recognition  of  which  they  occupy  the  foremost 
place.     A  few  words  here,  however,  on  the  sensations  of  patients. 

Sensations  of  Patients. — Sick  persons  are  subject  to  many 
disagreeable  feelings.  They  complain  of  chills,  of  heat,  of  lan- 
guor, of  restlessness,  and  of  uneasiness ;  but  their  most  constant 
complaint  is  of  pain.  Now,  pain  may  be  of  various  kinds:  it 
may  be  dull  or  gnawing ;  it  may  be  acute  and  lancinating.  In 
its  duration  it  may  be  permanent  or  remitting.  A  dull  pain  is 
generally  persistent.  It  is  most  often  present  in  congestions,  in 
subacute  and  chronic  inflammations,  and  where  gradual  changes 
of  tissues  are  taking  place.  It  is  the  pain  of  chronic  rheumatism, 
and  shades  off  into  the  innumerable  aches  of  this  malady.  The 
only  acute  affections  in  which  it  is  apt  to  exist  are  inflammations 
of  the  parenchymatous  viscera  and  of  mucous  membranes. 

Acute  pain  is  in  every  respect  the  reverse  of  dull  pain.  It  is 
usually  remittent,  and  not  so  fixed  to  one  spot.  It  is  met  with  in 
spasmodic  affections,  in  neuralgia,  and,  with  extremely  sharp  and 
lancinating  pangs,  in  malignant  disease. 

Pain  varies  much  in  intensity;  it  is  sometimes  so  extreme  as 
to  cause  death.  We  have  to  judge  of  its  severity  partly  on  the 
testimony  of  the  sufferer,  partly  by  the  countenance,  and  partly 
by  the  attending  functional  disturbances.  The  latter  are  not  to 
be  overlooked,  for  they  enable  us,  to  some  extent,  to  appreciate 
whether  the  torments  are  as  great  as  they  are  represented  to  be. 

The  seat  to  which  the  pain  is  referred  is  far  from  being  always 
the  seat  of  the  disease.  A  calculus  in  the  bladder  may  produce 
dragging  sensations  extending  down  the  thighs ;  inflammation  of 
the  hip-joint  gives  rise  to  pain  in  the  knee ;  disorders  of  the  liver 
occasion  pain  in  the  right  shoulder.  Pain  felt  at  some  part 
remote  from  that  affected  is  either  transmitted  in  the  course  of 
a  nerve  involved,  or  is  sympathetic. 

The  same  abnormal  action  does  not  always  create  the  same  kind 
of  pain.  Inflammation,  for  instance,  causes  different  pain  as  it 
involves  different  structures  :  the  pain  from  an  inflamed  pleura  is 
not  the  same  as  that  from  an  inflamed  muscle.  Speaking  gen- 
erally, the  tissues  themselves  seem  to  determine  the  form  of  pain 
more  certainly  than  does  the  precise  character  of  the  morbid 
process.     Thus,  pain  in  diseases  of  the  periosteum  and  bones,  no 


44  MEDICAL,    DIAGNOSIS. 

matter  what  may  be  the  exact  nature  of  the  malady,  is  mostly 
boring  and  constant;  in  the  serous  membranes,  sharp;  in  the 
mucous  membranes,  dull ;  and  in  the  skin,  burning  or  itching. 

Pain  produced  by  pressure  is  called  tenderness.  It  indicates 
increased  sensibility,  and  is  most  constantly  associated  with  inflam- 
mation. Yet  tenderness  may  be  present  without  inflammation  ; 
the  tenderness,  for  example,  of  the  skin  in  hysteria.  Commonly 
it  is  combined  with  pain  occurring  independently  of  pressure;  but 
a  part  may  be  tender  and  not  painful. 

Temperature  of  the  Body. — There  is  one  more  symptom 
of  general  significance  which  must  be  mentioned,  namely,  that 
connected  with  the  function  of  calorification,  and  based  on  the 
determination  of  the  heat  of  the  body.  To  measure  this,  a  ther- 
mometer is  necessary  ;  and  the  thermometry  of  disease  has  been 
of  late  years  very  carefully  studied,  and  has  been  found  to  afford 
much  aid  in  the  recognition  of  morbid  states,  particularly  of 
febrile  conditions,  and  of  affections  attended  with  marked  tissue- 
change. 

The  thermometer  used  for  clinical  purposes  should  be  very 
sensitive,  and  requires  to  be  compared  with  a  standard  one,  and 
verified.  A  convenient  form  is  to  have  it  curved,  and  with  an 
elongated  bulb.  The  scale,  extending  from  about  85°  to  115° 
Fahr.,  ought  to  be  uniformly  graduated.  For  careful  investi- 
gations it  should  be  divided  so  as  to  exhibit  fifths  of  a  degree. 

More  useful  still  than  the  ordinary  curved  instrument  is  the 
clinical  self-registering  thermometer  (Fig.  3).  A  straight  ther- 
mometer, usually  made  shorter  than  the  curved  one,  it  has  the 
mercury  detached  from  the  column.  This  detached  part,  or  the 
index,  is  set  by  bringing  it  down  below  the  lines  of  the  scale  by 
a  rapid  swing  of  the  arm.  After  the  thermometer  has  been  in 
position  for  the  required  period,  it  is  removed,  and  the  end  of  the 
index  farthest  from  the  bulb  records  the  maximum  temperature. 

A  good  surface  thermometer  for  localized  thermometry  is  also 
most  desirable.  Dr.  Edward  Seguin*  has  suggested  one,  which 
is  easily  applied  to  any  surface  (Fig.  4).  And  there  are  others 
which  are  now  coming  into  use  which  answer  a  still  better  pur- 
pose.    I  habitually  employ  one  which  has  the  mercury  in  a  fine 

*  Abridged  translation  of  Wunderlich's  Thermometry,  New  York,  1871. 


EXAMINATION    OF    PATIENTS,    ETC. 
Fig.  2.  Fig.  3.  Fig.  4. 


Thermometer  for  clinical  purposes. 
Nearly  natural  size. 


Self-Registering  Thermome- 
ter, showing  the  index 
marking  99°  shortly  after 
an  observation. 


45 


Fig.  5. 


The  Thermo- 
scope. 


46  MEDICAL    DIAGNOSIS. 

coil  at  the  expanded  extremity,  and  which  is  self-registering.  The 
ordinary  straight  self-registering  clinical  thermometer  may  be 
made  use  of,  with  the  bulb  fitted  into  a  piece  of  cork.  Whatever 
instrument  be  resorted  to,  we  should  first  obtain  the  heat  of  a  cor- 
responding or  analogous  well  part,  and  then  leave  the  bulb  for 
five  minutes  on  the  suspected  abnormal  structure.  Better  still  is 
it  to  apply  two  instruments  at  the  same  time;  one  on  the  sound, 
the  other  on  the  unsound  side.  In  all  observations  the  heat  of 
the  body,  as  ascertained  in  the  axilla,  should  also  be  noted. 

Still  another  instrument,  very  delicate,  and  designed  chiefly  to 
show  the  activity  of  the  heat-making  function,  is  the  thermoscope, 
also  invented  by  Scguin.  Fig.  5  explains  it.  The  bulb  is  heated, 
and  the  open  end  of  the  tube  is  then  plunged  into  cold  water. 
The  drop  or  two  which  run  up  to  near  the  bulb  become  the  index. 
The  thermoscope  may  be  applied  to  any  surface.  Its  best  place 
is  in  the  closed  hand,  and  in  five  or  ten  seconds  the  index  will 
attain  the  maximum  height  or  fall.  To  make  very  correct  obser- 
vations, a  mobile  scale  is  attached  to  the  stem,  and  its  lowest 
figure  is  to  be  put  on  a  level  with  the  head  of  the  water-index.* 

Thermo-electric  apparatus  have  also  been  employed  for  surface 
thermometry,  and  certainly  give  very  accurate  results  in  deter- 
mining differences  of  temperature  between  various  parts  of  the 
body.  But,  unless  the  instrument  of  Lombard "j"  should  prove 
an  exception,  they  are  not.  sufficiently  portable  or  easily  enough 
managed  to  come  into  general  use. 

In  using  surface  thermometers,  we  must  bear  in  mind  that  the 
local  temperature  is  as  a  rule  lower  by  upwards  of  one  or  by  sev- 
eral degrees  than  the  general  temperature.  We  find  it  so  on  the 
chest,  on  the  abdomen,  and  on  the  head.  The  temperature,  too, 
is  not  on  corresponding  sides  entirely  the  same,  at  least  not  on  the 
head.  Thus,  Lombard,  by  many  experiments,  has  become  con- 
vinced that  there  is  almost  always  a  slight  inequality  in  the  tem- 
perature of  the  two  sides  of  the  head ;  Gray  J  demonstrates  that 
when  at  rest  the  temperature  of  the  left  hemisphere  is  the  higher, 
which  accords  with  Broca's  statement.     And  some  recent  obser- 


*  Paper  read  before  the  New  York  State  Medical  Society,  1875. 
f  British  Medical  Journal,  Jan.  1875,  and  "  On  the  Kegional  Temperature 
of  the  Head,"  London,  1879. 

X  Chicago  Journal  of  Mental  and  Nervous  Diseases,  1879. 


EXAMINATION    OF    PATIENTS,    ETC.  47 

rations  of  Amidon*  have  shown  that  excessive  use  of  a  group  of 
muscles  may  generate  heat  in  the  cortical  region  presiding  over 
them,  sufficient  to  manifest  itself  to  surface  thermometers  placed 
on  the  scalp.  The  mean  temperature  of  a  healthy  man's  head  is 
fixed  by  Maragliano  and  Seppili,  as  the  result  of  many  observa- 
tions, at  36.13°  Cent,  (97.03°  Fahr.)  for  the  left  side  of  the  head, 
and  36.08°  Cent.  (96.9°  Fahr.)  for  the  right.f  These  tempera- 
tures are  much  higher  than  those  given  by  Broca  and  Gray,  which 
is  accounted  for  by  their  having  been  taken  in  summer.  Broca 
places  the  frontal  region  on  the  left  side  of  the  head  at  35.43°  Cent. 
(95.79°  Fahr.),  on  the  right  at  35.22°  Cent.  (95.39°  Fahr.); 
Gray's  figures  are  somewhat  lower.  The  parietal  region  on  the 
right  side  is  fixed  by  Broca  at  92.8° ;  by  Gray  at  93.6°  on  the 
right,  and  94.4°  on  the  left;  the  vertical  by  Gray  at  91.7°,  and 
the  occipital  at  91.9°  ;  the  whole  side  of  the  head  by  Broca 
at  about  93° ;  the  entire  head  at  places  remote  from  these  points 
at  93.5°  by  Gray.J  As  regards  the  abdomen,  Peter§  places  the 
normal  mean  of  the  parietes  at  35.5°  Cent,  (95.9°  Fahr.),  and  the 
same  observer,  who  has  given  so  much  attention  to  the  subject  of 
local  temperatures,  records  the  normal  temperature  for  the  chest- 
walls  at  about  36°  Cent.  (96.8°  Fahr.). 

But  to  return  to  general  thermometry.  It  is  a  matter  of  dispute 
how  most  appropriately  to  place  the  clinical  thermometer.  To 
put  it  under  the  tongue  or  in  the  rectum  has  been  strongly  recom- 
mended. But  the  most  suitable  site  is  the  axilla.  The  bulb  is 
pressed  into  the  armpit  and  kept  in  close  contact  with  the  skin  for 
five  minutes,||  and  the  degrees  marked  are  read  off  while  it  is  still  in 
position,  unless  a  self-registering  thermometer  be  employed.  The 
instrument  may  be  conveniently  introduced  just  below  the  skin 
covering  the  edge  of  the  pectoralis  major  muscle ;  and,  to  insure 
exactness,  the  patient  should  be  kept  in  bed  for  one  hour  before 

*  ]SI"ew  York  Archives  of  Medicine,  April,  1880. 

f  Translated  in  Alienist  and  ISTeurologist,  St.  Louis,  Jan.  1880. 

j  Xew  York  Archives  of  Medicine,  1879,  vol.  ii. 

|  Communication  to  Academie  de  Medecine,  quoted  in  Medical  Times  and 
Gazette,  Dec.  1879. 

||  Yet,  even  after  this,  the  thermometer  may  go  on  rising.  Indeed,  the 
variations  may  extend  over  an  hour.  (See  the  observations  of  Goodhart  in 
Guy's  Hospital  Eeports,  3d  Series,  vol.  xv.)  I  think,  however,  that  for  prac- 
tical purposes  the  statement  in  the  text  is  correct. 


48  MEDICAL    DIAGNOSIS. 

the  examination,  and  the  axilla  be  well  covered.  The  best  posture, 
as  Ringer  points  out,  is  neither  completely  on  the  back  nor  on 
the  side,  but  diagonally  on  the  right  or  the  left  side. 

In  all  cases  of  importance,  not  less  than  two  observations  should 
be  made  daily,  and  every  day  at  the  same  hour.  Between  seven 
and  nine  o'clock  in  the  morning,  and  about  seven  o'clock,  or 
somewhat  earlier,  in  the  evening,  are  regarded  as  the  most  appro- 
priate periods.  If  only  a  single  observation  be  taken,  it  is  best 
done  in  the  afternoon  or  evening.  Before  placing  the  thermometer 
in  position,  it  should  be  warmed  in  the  hand  or  slightly  heated  in 
water ;  and  in  every  record  of  the  temperature,  the  pulse  and  the 
respirations  must  also  be  noted. 

In  temperate  climates  the  average  heat  of  the  body,  as  measured 
in  the  axilla,  is  estimated  by  Wunderlich  at  37°  Centigrade;  that 
of  freshly-voided  urine  is  about  the  same.*  Expressed  in  the  scale 
used  in  this  country  and  in  England,  it  may  be  stated  that  the 
average  heat  of  sheltered  and  internal  parts  of  the  body  is  98.6° 
Fahr.f  This,  at  least,  is  the  case  in  the  axilla ;  in  the  rectum  it  is 
nearly  1°  higher;  in  the  mouth  somewhat  lower.  The  body  tem- 
perature rises  with  the  temperature  of  the  air,  and  fluctuates  slightly 
during  the  day,  being  in  temperate  climates,  according -to  the  most 
trustworthy  observers,  lowest  between  two  and  eight  in  the  morn- 
ing, and  highest  late  in  the  afternoon.  It  is  heightened  by  exercise, 
and  reduced  by  sustained  mental  exertion,  and  changes  even  when 
we  are  at  rest.t  But,  as  a  rule,  no  cause  except  disease  induces  a 
variation  of  much  more  than  1°;  and  even  in  the  extreme  heat 
of  tropical  climates  the  animal  heat  does  not  surpass  99.5°.  Thus 
a  temperature  above  this,  or  more  than  a  degree  below  the  average 

*  Die  Eigenwarrne  in  Krankheiten.  Translated  by  New  Sydenham  So- 
ciety. 

f  It  may  be  useful,  for  the  sake  of  comparing  the  results  of  observers  in 
different  countries,  to  recall  the  fact  that  one  degree  of  Fahrenheit  is  equal 
to  five-ninths  of  a  degree  of  the  Centigrade  thermometer,  and  four-ninths  of 
a  degree  of  Reaumur  ;  and  also  that  the  freezing-point  of  the  first  is  placed 
at  •'!2°  ;  that  of  the  others  at  zero.  To  convert  Centigrade  into  Fahrenheit, 
we  multiply  by  9  and  divide  by  5;  to  convert  Reaumur,  we  multiply  by  9 
and  divide  by  4.  and  when  above  zero,  in  either  case,  add  32.  To  convert 
Fahrenheit  above  zero  into  Centigrade,  we  subtract  32,  multiply  by  5,  and 
divide  by  0. 

X  See  an  instructive  paper  by  Garrod.  on  the  Minor  Fluctuations  of  the 
Temperature  of  the  Human  Body,  Proceedings  of  Royal  Society,  May,  1869. 


EXAMINATION    OF    PATIENTS,    ETC.  49 

stated,  when  persistent,  indicates  some  morbid  action  in  the  econ- 
omy. At  all  events,  it  does  so  in  adults ;  in  very  aged  persons  a 
temperature  of  97°  may  still  be  normal ;  and  we  must  bear  in 
mind  that  in  children,  in  whom,  too,  the  temperature  is  somewhat 
higher  than  in  adults,  the  daily  range  is  much  greater.  There 
may  be  a  fall  in  the  evening  amounting  to  between  2°  and  3°.* 
A  further  point,  too,  to  be  taken  into  account  in  those  of  all  ages 
is,  that  the  temperature  is  influenced  by  food  and  stimulants. 
And  these  are  the  elements  apt  to  be  overlooked,  and  which  make 
deductions  from  single  observations  or  comparatively  slight  changes 
untrustworthy. 

In  ordinary  cases  the  pulse  and  temperature  rise  synchronously, 
and  every  degree  above  98°  Fahr.  corresponds  with  an  increase 
of  ten  beats  of  the  pulse.  The  fever  temperature  ranges  from 
100°  to  106°.  When  it  exceeds  this,  the  patient  may  be  looked 
upon  as  in  danger,  except  the  rise  be  due  to  malarial  fever. 
Under  these  circumstances  it  is  rapid,  occurring  in  a  person  who 
yesterday,  or  but  a  few  hours  before,  was  healthy.  In  typhoid 
fever  the  thermometer  during  the  earlier  stages  does  not  rise  to 
more  than  103.5°  Fahr.  in  the  evening,  and  is  lower  in  the  morn- 
ing; at  any  period  of  its  course,  a  temperature  of  105°  is  a  proof 
of  grave  disease.  In  some  severe  cases  of  yellow  fever  the  heat  in 
the  armpit  has  been  noted  as  108°. f  In  pneumonia  a  tempera- 
ture above  104°  is  a  symptom  of  a  very  serious  seizure ;  so,  too, 
is  it  in  acute  rheumatism  a  symptom  either  of  danger  or  of  some 
complication.  "Stability  of  temperature,"  says  Aitken,J  "from 
morning  to  evening,  is  a  good  sign ;  on  the  other  hand,  if  the 
temperature  remains  stable  from  evening  till  the  morning,  it  is  a 
sign  that  the  patient  is  getting  or  will  get  worse."  In  convales- 
cence the  temperature  declines  until  it  attains  its  norm,  or  even 
falls  somewhat  below  this.  If  after  the  defervescence  the  ther- 
mometer again  indicate  a  decided  rise,  it  shows  a  return  of  the 
malady,  or  the  supervention  of  some  complication  or  new  disor- 
der ;  and  the  persistence  of  even  a  slight  degree  of  abnormal  heat 
after  apparent  convalescence  is  a  sign  of  imperfect  recovery,  or  of 
the  existence  of  some  lingering  secondary  complaint.     Further,  in 

*  Finlayson,  Glasgow  Medical  Journal,  Feb.  1869. 
f  Wragg,  Charleston  Medical  Journal,  vol.  s. 
j  Science  and  Practice  of  Medicine. 
4 


50  MEDICAL    DIAGNOSIS. 

cases  of  low  fevers,  the  skin,  particularly  of  the  hands  and  feet, 
may  feel  cool,  -while  the  instrument  in  the  axilla  marks  104°. 

Specific  forms  of  febrile  diseases  have  their  characteristic  vari- 
ations of  temperature.  In  measles,  for  instance,  the  temperature 
rises  toward  the  breaking  out  of  the  rash,  reaches  its  height  with 
the  period  of  eruption,  and  in  the  twenty-four  hours  succeeding  it 
falls  rapidly.  In  scarlet  fever  the  thermometer  marks  105°  or 
106°,  or  upwards,  with  but  a  slight  decline,  until  after  the  ninth 
day,  when  the  heat  gradually  subsides.  Typhoid  fever  has  its 
characteristic  record ;  so  have  the  malarial  fevers. 

A  temperature  above  107°  is  almost  certain  to  be  the  forerun- 
ner of  a  fatal  issue.  But  recovery  may  take  place.  In  a  case  of 
cerebral  rheumatism  under  my  charge*  the  thermometer  marked 
110°  in  the  axilla,  yet  the  patient  got  well.  And  in  an  instance 
of  injury  to  the  spine  after  a  fall,  reported  by  Mr.  Teale  to  the 
Clinical  Society,!  the  young  lady  lived  though  the  temperature 
reached  above  122°  and  ranged  for  days  between  112°  and  114°. 
A  remarkable  case  has  also  been  recently  reported  of  hysteria 
and  intercostal  neuralgia,  in  which  in  one  axilla  the  temperature 
registered  117°  Fahr.  and  110°  in  the  other,  yet  the  patient 
recovered.^ 

On  the  other  hand,  the  thermometer  may  show  a  fall  in  tem- 
perature below  the  normal.  It  rarely,  however,  even  in  extreme 
collapse,  sinks  below  92°. 

Though  having  its  widest  range  of  applicability  in  fevers,  in 
other  than  febrile  states,  too,  the  thermometer  assists  materially 
in  diagnosis  and  prognosis.  It  is  invaluable,  in  many  instances, 
in  discriminating  between  functional  and  organic  affections.  It 
aids  in  the  study  of  apoplexy,  of  palsies,  and  of  hysterical  af- 
fections, and  tells  the  true  story  in  cases  of  feigned  disease.  It 
also  enables  us  to  judge  whether  increased  frequency  of  pulse  be 
due  to  fever  or  to  debility;  and  it  indicates  that  sweating  which 
is  not  preceded  by  a  previous  elevation  of  temperature  is  the  result 
and  not  the  source  of  exhaustion.  There  is  probably  a  continu- 
ous rise  of  the  heat  of  the  body  in  all  cases  in  which  a  deposition 
of  tubercle  is  taking  place  actively  in  any  of  its  organs,  and  more 

*  See  Amer.  Journ.  of  Med.  Sci.,  Jan.  1875. 

f  London  Lancet,  March,  187o. 

J  Philipson,  London  Lancet,  April,  1880. 


EXAMINATION    OF    PATIENTS,    ETC.  51 

especially  in  the  lungs;  while,  on  the  other  hand,  I  have  noticed 
that  in  cancerous  affections  the  heat  of  the  body  is  but  little  in- 
fluenced, and  is  sometimes  even  below  the  normal  standard. 

Such  are  some  of  the  main  facts  connected  with  the  thermom- 
etry of  disease ;  and  in  the  course  of  this  volume  there  will  often 
be  occasion  to  refer  to  others.  Yet  even  those  here  mentioned  are 
sufficient  to  show  that  the  accurate  study  of  the  temperature  may 
be  of  much  service  in  the  recognition  of  a  malady  and  in  fore- 
telling; its  issue. 


CHAPTER  II. 

DISEASES   OF  THE   BRAIN   AND  SPINAL   COED,  AND   OF 
THEIK  NERVES. 

The  study  of  the  disorders  of  the  brain,  and,  in  truth,  of  those 
of  the  entire  nervous  system,  is  very  difficult.  Yet  great  advance 
lias  been  made  of  late  years  in  untangling  many  knotty  problems; 
and  at  least  the  more  tangible  evidences  of  nervous  disease  are 
much  more  clearly  recognized.  It  is  these  with  which  this  sketch 
is  intended  to  deal. 

But  first,  to  examine  a  few  symptoms  and  morbid  states  having 
a  general  significance  rather  than  a  specific  connection  with  any 
malady. 

DERANGED   INTELLECTION. 

The  great  instrument  of  the  intelligence,  the  brain,  manifests 
its  ailings,  whether  primary  or  merely  sympathetic,  by  derange- 
ment of  thought  of  every  conceivable  degree  and  kind, — from 
dulness  and  confusion  of  the  intellect  to  its  utter  perversion  and 
prostration.  When  one  intellectual  function  is  disturbed,  generally 
all  are,  or  soon  become  so;  yet  we  may  find  impairment  of  judg- 
ment and  of  imagination  without  deterioration  of  memory  or  of 
the  powers  of  attention.  One  of  the  most  marked  signs  of  mental 
infirmity  is  a  disordered  memory.  This  is  especially  encountered 
in  chronic  cerebral  diseases,  or  in  such  nervous  affections  of  un- 
certain seat  as  epilepsy.  Another  signal  of  mental  derangement  is 
loss  of  judgment,  or  rather  loss  of  power  to  appreciate  the  logical 
sequence  of  ideas ;  still  another  is  depression  of  mind,  or  its  op- 
posite, exaltation.  All  these  abnormal  conditions  may  happen  in 
acute  as  well  as  in  chronic  maladies,  but  they  are  more  striking  in 
the  latter,  and  become  of  more  aid  in  the  diagnosis ;  and  they  may 
or  may  not  be  joined  to  appreciable  textural  changes.  To  the 
psychologist  their  significance  is  very  great,  as  they  are  often  the 
52 


DISEASES    OF    THE    BEAIX    AXD    SPINAL    COED.  53 

only  premonitory  symptoms  of  that  departure  from  mental  health 
which  terminates  in  confirmed  insanity. 

In  acute  disturbances  of  the  brain,  whether  functional  or  or- 
ganic, we  meet  with  these  striking  phenomena  connected  with 
disordered  intellection :  delirium,  stupor,  coma ;  and  with  these 
we  may  consider  insomnia. 

Delirium. — This  is  a  wandering  of  the  mind,  manifesting  itself 
by  the  expression  of  ill-associated  thoughts,  of  the  incongruity  of 
which  the  patient  is  not  conscious.  It  most  frequently  occurs  in 
those  of  susceptible  nervous  system,  and  is,  in  consequence,  more 
common  in  the  young  than  in  the  old.  It  is  almost  invariably 
united  with  restlessness,  and  increases  as  night  approaches. 

The  character  of  the  delirium  is  various.  There  is  first  the 
quiet  delirium,  of  a  low  or  passive  type.  The  patient  mutters 
incoherent  words,  moans  without  any  assignable  reason,  or  lies 
silent,  with  his  eyes  open,  his  thoughts  preoccupied  with  his  vague 
illusions,  and  taking  no  notice  of  what  goes  on  around  him  in  the 
external  world.  If  strongly  aroused,  he  gives  a  rational  answer, 
but  not  a  long  or  a  connected  one,  for  he  soon  returns  to  his 
dreams  and  his  ever-changing  hallucinations.  He  picks  at  his 
bedclothes,  moves  in  bed,  and  may  even  try  to  leave  it,  although 
he  is  easily  prevented  from  so  doing. 

Then  there  is  a  delirium  of  somewhat  more  active  type,  still,  on 
the  whole,  quiet ;  the  patient  wanders,  yet  not  boisterously.  He 
is  irritable,  and  often  does  not  show  that  his  mind  is  disturbed, 
except  in  some  one  particular, — in  irascibility  about  trifles,  or  in 
expressions  and  modes  of  thought  foreign  to  his  nature. 

An  active,  fierce  delirium  presents  different  characteristics.  The 
patient  is  wild,  noisy ;  he  sings,  screams,  gets  out  of  bed ;  his  face 
during  the  excitement  becomes  congested ;  the  eye  is  bright,  often 
fiery. 

Now,  all  these  forms  of  delirium  occur  in  many  different  mala- 
dies, and  are  far  from  being  of  necessity  linked  to  an  organic 
cerebral  affection.  Nay,  not  even  the  most  violent  kind  of  mental 
wandering  is  positively  indicative  of  a  lesion  of  the  brain ;  at  least, 
not  of  such  a  lesion  as  can  be  determined  by  the  aid  of  the  scalpel, 
or  indeed  by  any  of  our  present  means  of  investigation.  As  a 
rule,  we  find  the  low,  quiet  delirium  in  conditions  of  vital  ex- 
haustion, particularly  in  those  depressed  states  of  the  nervous 


54  MEDICAL    DIAGNOSIS. 

system  which  are  connected  with  quickened  vascular  action,  and 
with  a  deterioration  of  the  blood,  as,  for  instance,  in  the  low 
fevers.  The  fierce  delirium  may,  however,  be  associated  with 
prostration  or  depraved  blood.  Thus,  the  delirium  of  pneumonia 
is  sometimes  of  a  violent  kind,  owing  to  the  maddening  effect  of 
the  ill-oxygenated  vital  fluid  on  the  brain.  In  most  of  the  ordi- 
nary fevers  the  delirium  is  of  a  moderate  type;  in  inflammatory 
diseases  of  the  brain  and  in  acute  mania  it  is  fierce. 

Delirium  is  not  difficult  of  recognition  ;  yet  we  must  be  careful 
not  to  confound  with  it  night  terrors,  those  troubled  dreams  to 
which  ailing  children  are  so  liable,  and  which  occasion  confusion 
of  thought  on  first  awaking,  and  until  consciousness  is  fully 
aroused.  Delirium  is  most  likely  to  be  mistaken  for  insanity. 
There  is,  however,  this  palpable  difference :  an  insane  person  is 
commonly  in  good  health  in  all  save  his  intellect;  a  delirious 
person  is  sick,  and  exhibits  other  evidences  of  his  sickness  in 
much  besides  his  delirium.  It  is  true  that,  when  the  patient  is 
first  seen,  doubt  may  arise ;  but  it  is  not  generally  of  long  dura- 
tion. In  the  mania  appearing  occasionally  after  epileptic  fits,  or 
taking  their  place,  there  may  be  doubt  until  we  obtain  a  clear  his- 
tory. Most  perplexing  are  the  cases  in  which  insanity  follows  or 
attends  inordinate  drinking.  But  this  is  a  subject  which  we  shall 
discuss  in  reviewing  the  clinical  phenomena  of  mania  a  potu. 

Another  perplexing  group  of  cases  is  furnished  by  the  occur- 
rence of  that  singular  form  of  delirium  which  is  met  with  at 
times  in  acute  diseases,  especially  in  fevers,  and  which,  as  it  is 
apt  to  be  associated  with  insufficient  nutrition,  has  been  called  the 
delirium  'of  inanition,  or  of  collapse.*  Its  outbreak  is  sudden, 
like  an  attack  of  mania,  but  it  is  found  to  be  combined  with  a 
feeble  pulse,  a  skin  bathed  in  perspiration,  cold  hands  and  feet, — 
in  a  word,  with  the  signs  of  great  prostration  or  of  collapse. 
The  seizure  happens  usually  early  in  the  morning,  and  is  unex- 
pected, for  it  occurs  commonly  at  the  end  of  the  febrile  state,  and 
when  the  condition  of  the  skin  and  pulse  bespeaks  convalescence. 
The  exhausted  nervous  centre  betrays  itself  in  the  sudden  mental 
wandering,  which  has  generally  this  characteristic, — there  is  but 
one  fixed    delusion,  and   this    one   connected   with   the  subjects 

*  See  Weber,  Medico-Chirurg.  Transact.,  I860;  Becquet,  Arch.  Gert.de 
Hedecine,  18G6 ;  also  the  Clinical  Lectures  of  Chomel  and  of  Trousseau. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  55 

which  have  most  engrossed  the  mind  before  the  illness.  The 
seizure  lasts  from  six  to  forty-eight  hours,  and  at  its  termination 
the  patient  is  apt  to  awake  out  of  a  sleep  with  a  calm  mind,  re- 
membering, perhaps,  his  hallucination  as  a  vivid  dream.  There 
may  be  more  than  one  attack,  but  this  is  not  common ;  and  the 
duration  is  materially  abridged  by  opium  and  the  employment  of 
stimulants  and  nourishment.  The  form  of  delirium  under  con- 
sideration has  been  spoken  of  as  linked  to,  or  rather  as  a  sequel 
of,  febrile  conditions.  But  it  may  also  succeed  exhausting  dis- 
charges and  drains  from  the  system,  or  inability  to  obtain  or 
to  digest  the  proper  amount  of  food.  Thus,  it  may  happen  in 
malignant  diseases  of  the  stomach ;  also  in  mere  gastric  irritability 
and  persistent  vomiting.  The  most  marked  instance  of  this  kind 
of  mental  wandering  I  have  encountered  was  associated  with 
functional  gastric  disorder,  which  prevented  enough  food  from 
being  retained.  In  this  patient  the  hallucination  was  on  one  sub- 
ject,— a  business  matter  which  had  been  annoying  him  greatly 
just  before  his  illness  assumed  a  decided  character. 

Delirium  is  sometimes  simulated.  I  saw  a  few  years  since  a 
striking  illustration.  It  differed  frpm  real  delirium  by  the  ab- 
sence of  all  other  signs  of  sickness,  and  by  the  sameness  of  the 
mental  wandering.  The  man  whined  when  spoken  to,  and  pre- 
tended to  rave ;  but  his  ideas  always  ran  on  the  same  subject,  and 
he  was  very  solicitous  about  his  food,  and  about  other  matters  of 
which  a  delirious  person  takes  no  notice  and  for  which  he  cares 
nothing.  Delirium  is  more  or  less  continuous ;  once  delirious,  a 
patient  remains  so  for  some  time,  and  until  the  exciting  cause 
subsides.  In  this  respect  hysterical  delirium  is  exceptional ;  it 
does  not  last  long,  or  it  intermits  and  then  reappears. 

Stupor. — A  blunted  state  of  mind,  a  partial,  drowsy  uncon- 
sciousness, constitutes  the  phenomenon  called  stupor.  The  patient 
lies  in  a  deep  slumber,  from  which  he  cannot  be  roused  save  with 
great  difficulty,  and  when  roused  he  answers  reluctantly  and 
briefly,  and  soon  resumes  his  heavy  sleep.  The  expression  of 
his  face  is  dull,  yet  now  and  then  a  ray  of  intelligence,  excited 
by  some  object  which  attracts  his  attention  or  by  some  pleasant 
reverie,  flits  across  his  features. 

Stupor  is  met  with  in  several  cerebral  affections,  and  seems  to 
be  chiefly  owing  to  a  congestion  of  the  brain.     It  is  frequently 


56  MEDICAL    DIAGNOSIS. 

seen  in  typhoid  fever,  immediately  after  an  epileptic  fit,  or  as  the 
result  of  narcotic  poisons ;  and  is,  in  these  states,  also  probably 
due  to  cerebral  congestion.  But  there  is  nothing  pathognomonic 
about  it  in  these  various  conditions,  nothing  by  which  we  can 
judge  positively  of  its  origin. 

Coma. — Coma  is  complete  loss  of  consciousness :  perception  and 
volition  are  alike  suspended,  and  there  is  an  appearance  of  the 
profoundest  sleep.  The  face  wears  a  confused  look ;  the  pupils 
are  sluggish,  often  dilated.  Sensation  may  be  blunted,  but  is  not 
destroyed;  nor  is  motion,  for  the  patient  moves  when  his  skin 
is  pinched  or  tickled.  Coma  is  always  of  grave  augury :  it  be- 
tokens a  very  serious  disturbance  of  the  functions  of  the  brain. 

Coma  is  often  witnessed  in  cerebral  lesions,  as  from  pressure 
from  blood  or  fluid  in  brain-substance  or  in  ventricles,  more 
rarely  from  tumors,  abscesses,  or  thrombosis.  The  most  thorough 
coma  is  seen  in  apoplexy ;  it  comes  on  very  quickly,  and  is  at- 
tended with  a  noisy  respiration  and  a  slow  pulse.  Another  form 
of  coma,  scarcely  less  complete,  is  caused  by  narcotic  poisoning; 
it,  however,  does  not  appear  suddenly,  and  when  from  opium  is 
associated  with  contraction  of  the  pupils.  The  coma  of  fevers  and 
of  acute  diseases,  whether  cerebral  or  not,  is  also  gradually  pro- 
duced, but,  unlike  that  due  to  the  toxical  effect  of  opium,  is  ordi- 
narily preceded  for  days  by  insomnia,  by  delirium,  and  by  other 
signs  of  cerebral  disturbance.  The  coma  of  epilepsy  is  recognized 
by  its  following  epileptic  seizures.  In  Bright's  disease,  among  the 
nervous  phenomena  of  which  coma  as  well  as  stupor  and  delirium 
may  happen,  the  loss  of  consciousness  is  apt  to  occur  subsequently 
to  either  of  the  two  other  morbid  phenomena,  and  its  cause  is  made 
manifest,  as  is  farther  on  more  particularly  explained,  by  finding 
albumen  and  tube-casts  in  the  urine,  and  by  the  general  evidences 
of  uraemia.  Ursemic  coma  may,  however,  come  on  suddenly  and 
pass  off  suddenly.  It  is,  as  a  rule,  associated  with  low  temper- 
ature. 

Sometimes  a  person  appears  to  be  comatose  when  his  intellect 
is  but  little  disordered.  He  may  be  paralyzed,  and  not  have  the 
power  to  communicate  his  ideas,  from  crippled  articulation  or  in 
connection  with  aphasia.  This  state  is  distinguished  from  coma 
by  noting  that  the  patient's  attention  is  always  directed  to  the 
questions  asked   him,  nay,  that  he  strives  to  answer  them,  but 


DISEASES    OF    THE    BRAES"    AND    SPINAL    CORD.  57 

cannot ;  and  that  generally  he  has  lost  control  over  the  muscular 
movements  of  one  side  or  of  both  sides  of  the  body. 

Insomnia. — The  deprivation  of  sleep  is  a  concomitant  of 
cerebral  congestion  and  of  the  earlier  stages  of  cerebral  inflamma- 
tion. But  a  person  may  be  sleepless  from  excessive  pain,  from 
exhaustion,  from  grief,  or  from  mental  excitement  or  fatigue;  and 
sometimes  insomnia  is  engendered  by  habitually  working  late  at 
night.  However,  in  several  of  these  states  congestion,  though  of 
a  passive  character,  is,  in  all  likelihood,  the  immediate  cause  of 
the  wakefulness. 

Insomnia  often  precedes  or  attends  delirium,  as  appears  in 
typhoid  fever.  Among  purely  nervous  affections  it  is  most  marked 
in  delirium  tremens.  It  is  a  very  troublesome  symptom ;  but, 
occurring  in  so  many  abnormal  conditions,  it  cannot  be  looked 
upon  as  having  a  distinct  and  specific  diagnostic  value. 

DERANGED   SENSATION. 

The  signs  of  perverted  or  impaired  sensation  are  numerous. 
They  may  be  either  due  to  an  alteration  of  the  general  sensibility 
or  the  signals  of  a  derangement  of  a  nerve  of  special  sense.  Let 
us  look  at  a  few. 

Hyperesthesia. — An  exalted  irritability  of  the  sensitive  sur- 
face nerves, — of  those  of  the  skin,  the  mucous  membranes,  or  even 
of  those  of  deeper-seated  structures, — in  other  words,  a  hyper- 
esthesia of  these  parts,  is  a  symptom  of  much  diagnostic  impor- 
tance; not  so  much,  perhaps,  on  account  of  the  light  thrown  on 
any  particular  disease  by  the  increased  sensibility,  as  because  its 
presence  makes  it  requisite  to  determine  its  origin  and  to  separate 
its  phenomena  from  those  of  inflammation.  And  in  truth  the 
distinct  acknowledgment  that  acute  sensibility  is  not  of  necessity 
inflammatory,  is  one  of  the  triumphs  of  modern  pathology.  We 
may,  as  a  rule,  distinguish  the  peripheral  sensitiveness  from  the 
tenderness  of  subjacent  inflammation,  by  its  extension  over  a  larger 
surface ;  by  deep  pressure  producing  no  more  pain  than  a  light 
touch ;  by  the  absence  of  signs  of  functional  disturbance  of  the 
part  apparently  involved  in  inflammatory  disease;  by  the  uni- 
formity of  the  symptoms,  no  matter  how  long  the  duration  of  the 
disorder ;  and  by  the  sensitiveness  exhibiting  distinct  intermissions 
and  exacerbations. 


58  MEDICAL    DIAGNOSIS. 

But  in  what  affections  do  we  encounter  hyperesthesia  ?  Is  it 
only  in  those  of  the  brain  or  spinal  cord?  By  no  means.  Indeed, 
we  may  say  that,  in  organic  diseases  of  these  structures,  such  at 
least  as  we  can  detect,  it  is  not  common,  and  rarely  reaches  a  high 
degree  of  development.  By  far  the  most  usual  causes  of  hyper- 
esthesia are  impoverished  blood  and  that  mysterious  malady  called 
hysteria;  therefore  conditions  which  bespeak  lowered  vital  and 
nervous  power.  Sometimes  hyperesthesia  is  produced  by  rheu- 
matism or  gout,  or  by  disturbance  of  the  function  of  the  kidney. 
It  is  further  met  with  in  epidemic  influenza;  in  hydrophobia;  in 
inflammations  in  internal  cavities  involving  the  ganglia  of  the 
great  sympathetic ;  after  the  use  of  ergot  and  of  opium ;  and  in 
some  diseases  of  the  skin.  It  also  attends  paroxysms  of  neural- 
gia, as  witnessed  in  the  exquisite  sensitiveness  of  the  skin  during 
an  attack  of  tic  douloureux;  the  painful  spots,  too,  in  the  course 
of  local  neuralgias  are  thought  to  be  chiefly  hyperesthetical. 

The  exaltation,  or,  perhaps,  more  strictly  speaking,  the  per- 
version, of  sensation  may  disclose  itself  in  other  signs  besides  pain 
and  tenderness;  in  a  general  irritability  of  the  surface,  in  itching, 
in  formication,  and  in  unnatural  feelings  of  various  kinds,  such 
as  the  feeling  of  "pins  and  needles,"  of  gooseflesh,  of  flushing,  of 
the  trickling  of  cold  water.  The  seat  of  the  heightened  sensi- 
bility is  ordinarily  in  the  skin,  in  the  distribution  of  the  cutaneous 
nerves.  Yet  hyperesthesia  may  affect  the  nerves  of  the  special 
senses,  manifesting  itself,  for  instance,  by  intolerance  of  light  or 
of  sound.  But  this  variety  of  hyperesthesia  need  here  be  but 
alluded  to,  as  we  shall  presently  look  more  fully  at  the  signs  of 
disturbance  of  these  nerves. 

Of  the  minute  anatomical  changes  in  hyperesthesia  we  know 
nothing.  Physiologically  speaking,  the  phenomenon  belongs,  for 
the  most  part,  to  an  irritative  condition  of  the  posterior  columns. 

Let  us  now  look  at  hyperesthesia  in  connection  with  affections 
of  the  nervous  system,  especially  with  those  of  the  brain  and  spinal 
cord. 

Hypermsthesla  is  general  and  combined  with  signs  of  organic 
disease. — We  find  this  state  of  things  in  tumors  pressing  upon  the 
pons  Varolii  and  corpora  quadrigemina,  or  in  alterations  or  in- 
juries of  the  posterior  columns  of  the  cord,  or  in  injuries  dividing 
transversely  and  completely  a  lateral  half  of  the  spinal  cord,  in 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  69 

some  cases  of  cerebral  meningitis,  and  in  spinal  meningitis  in 
which  the  posterior  nerve-roots  are  implicated.  We  have  in  all 
these  conditions  a  hyperesthesia  more  or  less  extensive,  and 
combined  with  other  striking  evidence  of  nervous  disease,  often 
with  pain.  But  in  making  up  our  minds  as  to  the  cause  of  the 
extended  hyperesthesia,  the  sensitiveness  in  general  neuralgias  and 
in  reflected  irritation  to  the  posterior  columns,  especially  in  hys- 
terical subjects,  must  always  be  remembered. 

Hyperesthesia  is  limited  to  one  side. — An  injury  or  degeneration 
of  only  one  posterior  column  will  give  us  increased  sensibility  on 
one  side,  on  the  same  side  as  the  lesion.  Limited  hyperesthesia 
belongs  much  more  closely  to  spinal  than  to  cerebral  disease.  We 
also  find  it  in  connection  with  special  neuralgias,  and  the  sensitive 
skin  shows  augmented  electrical  sensibility.  In  some  instances 
of  limited  as  well  as  of  more  extended  hyperesthesia  nothing 
abnormal  can  be  detected,  and  the  disorder  must  be,  with  our 
present  knowledge,  set  down  as  a  neurosis,  one  concerning  which 
it  remains  uncertain  whether  it  be  of  central  or  of  peripheral 
origin. 

AnSBSthesia. — Loss  of  sensation,  or  anaesthesia,  is  of  various 
degrees.  It  may  be  complete  or  partial, — a  perfect  absence  of 
sensibility,  or  its  mere  benumbing.  Not  to  speak  of  its  meaning 
when  displaying  itself  only  in  the  organs  of  the  special  senses, 
we  find  it  in  diseases  of  the  brain  ;  in  several  of  the  neuroses ; 
after  large  doses  of  Indian  hemp,  of  lead,  of  arsenic:  we  see  it 
ushering  in  attacks  of  neuralgia ;  accompanying  or  preceding 
cutaneous  eruptions,  such  as  elephantiasis  or  pemphigus;  in  hys- 
teria, in  syphilis,  in  rheumatism ;  and  as  the  result  of  diphtheria, 
of  pressure  on  nerve  trunks,  of  perij^heral  nerve  irritation,  and  of 
disturbances  of  circulation  and  abnormal  conditions  of  the  blood. 
In  the  mucous  membranes,  too,  it  may  exist,  in  consequence  either 
of  the  general  causes  just  mentioned,  or  of  some  purely  local 
irritation;  and  it  may  affect  the  muscles.  But  it  does  not  attack 
these  structures  nearly  as  often  as  it  does  the  skin  :  indeed,  this 
is  so  well  understood  that,  when  we  speak  of  anesthesia  with- 
out qualifying  it,  we  mean  that  of  the  cutaneous  nerves.  In  the 
parts  affected  with  anesthesia  the  nutrition  is  less  active,  and 
there  is  a  feeling  of  numbness.  The  temperature  is  diminished, 
and,  if  the  impaired  sensibility  be  at  all  general,  the  patient  is 


60  MEDICAL    DIAGNOSIS. 

not  susceptible  to  alternations  of  heat  and  cold.  Frequently 
the  circulation  in  the  skin  is  retarded,  occasioning  a  perceptible 
lividity  and  discoloration  of  the  surface ;  or  there  are  coexisting 
trophic  changes,  such  as  glazing  of  the  skin,  and  grayness  of 
hair.  The  electrical  sensibility  is  diminished,  as  is  made  very 
manifest  by  the  use  of  the  wire  brush  with  either  the  faradaic  or 
the  galvanic  current.  In  hysterical  anaesthesia  this  is  a  particu- 
larly striking  feature. 

Loss  of  sensation  has  a  much  more  constant  connection  with 
organic  affections  of  the  nervous  centres  than  increased  sensi- 
bility, which,  however,  may  precede  it.  In  the  insane,  especially 
in  monomaniacs,  anaesthesia  is  very  common,  and  ordinarily  very 
extended;  so,  too,  in  general  paralysis.  Indeed,  with  few  excep- 
tions, an  extended  anaesthesia  points  to  an  affection  of  the  nervous 
centres.  Localized  anaesthesia  may  usher  in  acute  attacks  of  cere- 
bral disease,  and  indeed  sometimes  exists  for  years  before  any 
marked  cerebral  symptoms  are  perceived.  Thus,  a  case  of  apo- 
plexy was  observed  by  Andral*  in  which  deficient  sensation  was 
noticed  at  various  portions  of  the  thorax  for  a  long  time  previous 
to  the  loss  of  consciousness ;  another,  in  which  the  tips  of  the 
fingers  were  benumbed,  and  felt  continually  as  if  they  had  been 
subjected  to  intense  cold.  Forbes  Winslowf  mentions  instances 
in  which  circumscribed  conditions  of  impaired  sensation  were  the 
premonitory  symptoms  of  softening  of  the  brain;  the  defective 
feeling  being  manifested  in  some  cases  in  the  skin,  in  others  in  the 
tongue  and  fauces. 

If  the  defective  sensibility  be  owing  to  a  spinal  malady,  it  is 
generally  found  in  the  lower  extremities,  and  coexists  with  paral- 
ysis. Anaesthesia  of  spinal  origin  is  usually  indicative  of  the 
gray  matter  of  the  cord  having  been  disturbed  or  altered ;  and,  in 
accordance  with  the  well-known  physiological  law  of  the  decussa- 
tion of  sensitive  impressions  in  the  cord,  disease,  if  only  of  one 
posterior  half,  is  followed  by  lost  sensation  on  the  opposite  side  of 
the  body.  One-sided  anaesthesia,  affecting  even  the  face  up  to  the 
middle  line,  is  sometimes  met  with  in  hysterical  subjects  as  the  re- 
sult of  ovarian  irritation,  or  after  typhoid  fever,!  and,  though  pre- 

*  Clinique  Medicale,  tome  v. 

f  Obscure  Diseases  of  the  Brain,  p.  549. 

X  Calmet,  Bulletin  de  la  Societe  Medicale  des  Hopitaux,  1876. 


DISEASES    OF    THE    BEAIN    AXD    SPIXAX,    CORD.  61 

sumably  cerebral,  the  pathology  is  unsettled.  But  strictly-limited 
one-sided  anaesthesia  is  more  apt  to  be  found  in  a  distinct  brain 
lesion,  and  the  particular  affection  occasioning  the  "hemianes- 
thesia" is  disease  of  the  white  substance  just  outside  of  the  optic 
thalamus,  of  the  posterior  part  of  the  internal  capsule,  on  the  side 
of  the  brain  opposite  to  the  side  of  the  body  which  shows  the 
anaesthesia.  The  insensibility  is  generally  complete  as  to  touch, 
pain,  temperature,  and  electricity.  Taste,  smell,  and  hearing  are 
also  abolished  on  the  one  side,  and  the  eye  on  the  anaesthetic  side 
loses  its  acuteness  of  vision  and  of  perception  of  color. 

A  localized  and  curious  form  of  anaesthesia  happens  now  and 
then  in  consequence  of  an  affection  of  the  fifth  nerve.  The  ex- 
tent of  loss  of  sensation  depends  very  much  upon  the  part  of  the 
nerve  at  which  the  cause  of  disturbance  is  seated.  The  skin  of 
the  nose  and  cheek  may  become  devoid  of  sensation ;  the  reflex 
movements  of  the  muscles  of  the  face  may  cease ;  the  conjunctiva, 
or  the  whole  surface  of  the  eye,  or  one-half  of  the  tongue,  may  be 
deprived  of  sensibility.  Only  one  of  these  phenomena,  or  all  con- 
jointly, may  be  encountered,  according  as  part  of  one,  or  one,  or 
all  of  the  branches  of  the  fifth  nerve  are  affected.  Sometimes, 
as  Romberg  proves,  trigeminal  ancesthesia  is  of  rheumatic  origin. 
When  it  is  complicated  with  disturbed  functions  of  adjoining 
cerebral  nerves,  it  may  be  assumed,  says  the  same  distinguished 
observer,  that  the  cause  is  seated  at  the  base  of  the  brain. 

Anaesthesia  is  sometimes  the  result  of  reflex  action.  It  may 
thus  arise  in  disorders  of  any  of  the  viscera,  and  from  an  irrita- 
tion of  any  sensitive  nerve.  It  has,  for  instance,  been  observed 
in  both  lower  limbs  in  sciatica,  as  we  find  in  some  striking  ob- 
servations in  the  tenth  lecture  of  Brown-Sequard's  work  on  the 
Central  Xervous  System. 

Very  often  numbness  and  other  altered  sensations  are  com- 
plained of,  and  yet  the  whole  is  subjective;  when  tested,  anaes- 
thesia is  not  found. 

In  endeavoring,  indeed,  to  form  a  correct  opinion  of  the  exist- 
ence or  the  completeness  of  anaesthesia,  it  will  not  do  to  trust  to 
the  patient's  statements.  "We  touch  the  part  lightly  with  the 
finger  or  a  feather  while  his  eyes  are  shut,  and  where  the  sense  is 
obviously  blunted  the  skin  is  pinched  or  a  pin  used  to  ascertain 
the  extent  of  the  impaired  sensation.     Or  we  resort  to  means  by 


62 


MEDICAL    DIAGNOSIS. 


which  we  can  make  accurate  comparisons;  and  one  of  the  best 
is  to  pursue  the  method  used  by  Weber  in  his  researches  on  the 
tactile  properties  of  the  skin.  It  consists  in  determining  how 
closely  the  points  of  a  pair  of  compasses  sheathed  with  cork  may 
be  approximated  on  the  skin  and  yet  be  felt  as  two  distinct  points. 
An  instrument  for  the  same  purpose,  called  the  "sesthesiometer," 
was  invented  by  Dr.  Sieveking  (Fig.  6),  and  can  be  applied  in 

Fig.  6 


The  aesthesiometer. 


paralysis  to  ascertain  the  amount  and  extent  of  sensational  im- 
pairment, as  a  means  of  diagnosis  between  actual  paralysis  of 
sensation  and  mere  subjective  anaesthesia  in  which  the  tactile 
powers  are  unaltered,  and  as  affording  us  assistance  in  deter- 
mining the  progress  of  a  case  of  palsy  for  better  or  for  worse. 
An  instrument  combining  the  principle  of  the  beam  compass  with 
that  of  the  mathematical  one  has  been  contrived  by  Ogle,*  and 
one  with  ivory  points,  by  Manouvriez.f  The  aesthesiometer  now 
usually  employed  is  very  simple,  and  answers  all  purposes, — a  pair 
of  compasses  with  points  somewhat  blunted,  and  with  a  gradu- 
ated segment  of  a  circle  attached  to  the  arms,  indicating  the  dis- 
tance at  which  the  points  are  apart.  The  points  should  be  put 
down  lightly  and  simultaneously,  and  parallel  with  the  direction 
of  the  cutaneous  nerves;  at  all  events  the  same  relative  direction 
should  be  preserved  in  making  comparative  estimates. 

To  understand  any  results  obtained  regarding  the  tactile  sense, 
it  is  necessary  that  we  should  be  aware  how  this  differs  in  some 
parts  of  the  body.     Most  works  on  physiology  contain  an  account 

*  Beale's  Archives  of  Medicine,  vol.  i. 
f  Archives  de  Physiologie,  1876. 


DISEASES    OF    THE    BRAIX    AXD    SPINAL    COED.  63 

of  the  researches  of  Weber  and  of  those  who  have  prosecuted  the 
inquiry  he  started.*  It  would  therefore  be  useless  to  quote  them 
here  at  length ;  yet  a  few  of  the  conclusions  may  be  advantageously 
mentioned.  At  the  tip  of  the  tongue  two  points  can  be  readily 
distinguished  when  separate  from  each  other  only  about  -^  of 
an  inch,  or  half  a  Paris  line ;  at  the  palmar  surface  of  the  third 
phalanx  the  limit  is  one  line;  on  the  palmar  surface  of  the  second 
phalanx,  two  lines,  the  same  on  the  red  surface  of  the  lips ;  on  the 
palm  of  the  hand,  the  cheek,  and  the  extremity  of  the  great  toe, 
five  lines;  on  the  back  of  the  hand,  at  the  knuckles,  eight  lines; 
at  the  lower  part  of  the  forehead,  ten  lines;  on  the  skin  over  the 
patella  and  dorsum  of  the  foot,  eighteen  lines ;  over  the  middle  of 
the  arm,  thigh,  and  over  the  spine,  thirty  lines.  But  these  obser- 
vations are  found  to  vary  somewhat  even  in  healthy  persons,  some 
being  able  to  distinguish  at  a  shorter  distance  than  others. 

Besides  the  impairment  or  loss  of  tactile  discrimination,  the 
altered  sensibility  may  show  itself  in  the  loss  of  the  faculty  of 
feeling  pinching,  pricking,  and  other  acts  which  excite  pain  (anal- 
gesia); or  in  insensibility  to  tickling;  or  in  the  want  of  apprecia- 
tion of  heat  or  cold ;  or  in  the  loss  of  the  sensation  which  attends 
muscular  contraction,  whether  produced  by  the  will  or  by  an  elec- 
trical current.  Now,  it  is  of  interest  in  individual  cases  to  note 
which  particular  kind  of  sensibility  is  affected,  though,  as  yet,  we 
are  not  in  possession  of  sufficient  facts  to  draw,  from  the  absence 
of  one  form  of  sensibility  or  the  other,  any  positive  conclusions  as 
to  the  seat  or  character  of  the  disease. 

In  affections  of  the  base  of  the  brain,  we  have  been  told  by 
Brown-Sequard,  there  is  this  peculiar  modification  of  tactile  im- 
pression, that  the  patient  feels  three  points  instead  of  the  two  of 
the  sesthesiometer.f  In  sclerosis  of  the  cord,  YulpianJ  informs 
us,  the  sensation  is  retarded  rather  than  lost. 

Muscular  ancesthesia  has  been  alluded  to.  It  is  closely  con- 
nected with  the  power  we  possess  of  estimating  weight,  the  "  mus- 
cular sense ;"  and  the  loss  of  the  power  of  perceiving  differences  in 
weight,  or  the  impairment  of  the  sense  of  muscular  movement  and 
effort,  is  probably  its  most  common  form.     Another  form  is  the 

*  See  especially  Carpenter's  article,  "Touch,"  in  Cyclopaedia  of  Anatomy 
and  Physiology ;  also  Valentin's  Lehrbuch  der  Physiologie. 

f  Archives  de  Physiologie,  i.  No.  3.  t  Ibid. 


64  MEDICAL    DIAGNOSIS. 

loss  of  the  power  of  appreciating  muscular  contraction,  and  the 
deficiency  of  sensation  is  then  most  readily  tested  by  electrical 
examination  ;  the  feeling  of  contraction  of  the  muscles  is  not  per- 
ceived. Muscular  anaesthesia  may  or  may  not  be  combined  with 
cutaneous  anaesthesia.  It  is  not  uncommon  in  hysteria  and  in 
locomotor  ataxia.  Here  the  loss  of  the  appreciation  of  the  position 
of  the  limbs  and  that  of  the  sense  of  muscular  effort  are  the  more 
usual  of  its  varieties. 

Anaesthesia  and  hyperesthesia  follow,  or,  to  speak  more  accu- 
rately, manifest  themselves  only  in  connection  with,  external  im- 
pressions. Let  us  now  look  at  some  abnormal  sensations  which 
are  not  objective,  but  subjective, — arising,  so  far  as  we  can  judge, 
independently  of  external  impressions.  Headache  and  vertigo 
are  of  this  character. 

Headache. — In  every  case  of  headache  we  must  first  ascertain 
that  the  pain  really  originates  within  the  cranium,  and  that  it  is 
not  owing  to  supra-orbital  neuralgia;  to  rheumatism  of  the  scalp; 
to  disease  of  the  bones ;  to  periostitis,  syphilitic  or  otherwise ;  or 
to  affections  of  the  ear.  To  accomplish  this  is  generally  not  diffi- 
cult. An  inquiry  into  the  history  of  the  case,  the  locality  of  the 
pain,  and  its  augmentation  on  pressure  in  most  of  the  disorders 
named,  furnish  evidence  which  decides  the  source  of  the  cephalal- 
gia to  be  external  to  the  cranium. 

Another  possible  cause  of  headache,  always  to  be  kept  in  mind, 
has  been  recently  made  clear  by  the  labors  of  eye-surgeons.  It 
occurs  in  persons  who  have  headache  more  or  less  intense,  with 
abnormal  sensations  in  the  skin  of  the  scalp,  and  at  times  vertigo 
and  spasm  of  the  eyelids  and  occipito-frontal  muscle.  The  near 
use  of  their  eyes  increases  their  distress.  When  the  eye  is  care- 
fully examined,  an  optical  defect  is  found,  especially  astigmatism. 
Again,  we  may  have  defective  vision,  with  sleeplessness  and  severe 
headache,  dependent  on  decayed  teeth,  and  disappearing  with  their 
removal.* 

Having  settled  that  none  of  these  conditions  are  present,  we 
have  to  determine  the  probable  cause  of  the  headache, — a  question 
the  solution  of  which  depends  frequently  more  upon  the  symptoms 
attending  the  pain  than  upon  its  character.     But  let  us  glance  at 

*  Case  reported  by  Ogle,  Medical  Times  and  Gazette,  Aug.  1872. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  65 

some  of  the  common  causes  and  characteristics  of  intra-cranial 
headache. 

Headache  is  a  rarely  absent  symptom  of  disease  of  the  brain. 
In  acute  inflammation  it  is  generally  agonizing,  and,  while  sub- 
ject to  exacerbations,  continuous ;  it  is  associated  with  fever,  with 
vomiting,  although  the  tongue  remains  clear,  and  with  delirium. 
In  abscesses  of  the  brain,  in  softening,  and  in  similar  affections 
which  run  a  chronic  course,  the  headache  is  less  violent,  and 
only  occasionally  paroxysmal ;  it  is  usually  accompanied  by  signs 
of  disturbed  intellection  and  of  deranged  motion.  In  tumor 
of  the  brain  the  headache  is  apt  to  be  severe  and  paroxysmal, 
but  intellection  is  not  at  first  much  disturbed.  In  congestion 
of  the  brain  the  pain  is  dull,  increased  by  stooping  or  lying 
down,  by  long  sleep,  and  by  bodily  or  mental  fatigue ;  its  con- 
comitants are  a  flushed  face,  throbbing  of  the  arteries  of  the  neck, 
an  eye-ground,  as  seen  with  the  ophthalmoscope,  in  which  the 
vessels,  especially  the  veins,  are  turgid,  and  a  heated  head,  with 
increased  temperature,  as  shown  by  the  surface  thermometer.  A 
kind  of  congestive  headache,  apt  to  be  relieved  by  bleeding  at 
the  nose,  is  the  form  so  often  seen  in  young  people  at  the  age  of 
puberty,  and  attacks  of  which  are  brought  on  by  running  or  other 
violent  exercise.  In  diseases  of  the  meninges,  especially  those  of 
a  chronic  character,  the  pain  is  constant  and  fixed,  and  sometimes 
very  sharp.  The  latter  kind  of  pain  when  persistent  is  significant 
either  of  disease  of  the  membranes,  or,  at  least,  of  parts  of  the 
superficial  structure  in  contact  with  them,  and  is  usually  felt  at 
the  place  on  the  head  which  corresponds  to  the  seat  of  the  lesion 
within  the  skull.  There  is  generally  in  meningeal  affections  co- 
existing heat  of  forehead,  with  signs  of  local  vascular  excitement. 

Nervous  or  neuralgic  headache  is  most  common  in  women, 
especially  in  anaemic  women.  It  is  unremitting  and  very  severe, 
yet  of  short  duration  ;  but  after  it  is  over  there  is  great  lassitude, 
and  even  some  local  soreness.  It  is  not  attended  with  rise  of 
temperature,  or  with  any  signs  of  disturbance  of  the  brain,  ex- 
cept at  times  with  a  confusion  of  vision  and  an  inability  to  carry 
on  a  connected  train  of  thought.  Anything  that  agitates  the  ner- 
vous system  produces  an  attack ;  stimulants  and  food  often  relieve 
it.  To  the  class  of  headache  under  consideration  may  be  referred 
many  cases  of  megrim  or  sick  headache. 

5 


Q6  MEDICAL    DIAGNOSIS. 

Sympathetic  headache  is  of  kindred  nature.  It  is  found  mainly 
in  connection  with  disorders  of  the  alimentary  tube  and  of  the 
uterus,  and  is  often  worse  in  the  morning,  before  food  has  been 
taken. 

Headache  may  be  dependent  upon  various  j>°^S01ls)  whether 
generated  in  the  system  or  introduced  from  without ;  for  instance, 
in  diseases  of  the  kidney  the  retention  of  a  large  quantity  of  urea 
in  the  blood  becomes  the  source  of  persistent  pain  in  the  head. 
In  lead  poisoning,  in  opium-eaters,  in  drunkards,  after  the  use  of 
strychnia  or  of  large  quantities  of  quinia,  headache  is  common. 

In  studying  headache  as  a  symptom,  we  must  always  note  what 
influence  position  and  movements  of  the  head  have  on  the  pain : 
whether,  for  instance,  stooping,  swinging  the  head  from  side  to 
side,  or  rising  rapidly  from  the  horizontal  to  the  erect  posture 
affect  it,  and  cause  it  to  be  combined  with  vertiginous  or  other 
abnormal  sensations. 

Vertigo. — This  is  a  transitory  feeling  of  swimming  of  the 
head,  a  sense  of  falling,  or  illusory  movements  of  external  objects. 
This  curious  sensation  is  apt  to  occur  whenever  the  circulation 
within  the  cranium  is  disturbed,  and  is  often  symptomatic  of  a 
disease  of  the  heart,  liver,  kidneys,  especially  Bright's  disease,  or 
of  an  affection  of  the  stomach  or  of  the  blood,  or  of  gout  or  lithse- 
mia ;  or  it  follows  long-continued  and  exhausting  discharges. 

Vertigo  may  attend  any  disorder  of  the  brain.  The  cerebral 
form  is  recognized,  in  part,  by  the  absence  of  those  affections  of 
other  organs  which  would  induce  the  dizziness, — and  among  these 
Ave  must  not  forget  eye-strain,  astigmatism,  and  local  palsies  of  the 
muscles  of  the  eyeball, — in  part,  by  its  being  joined  to  an  almost 
constantly  present  sense  of  uncertainty  in  movement,  to  headache, 
and  to  further  signs  of  an  encephalic  malady.  Moreover,  it  is 
usually  objective  in  character :  surrounding  objects  appear  to  the 
patient  to  move,  not  he  himself;  and,  unlike  the  subjective  ver- 
tigo, so  common  in  mere  sympathetic  disturbance  of  the  brain, 
closing  the  eyes  relieves  it. 

The  most  common  form  of  vertigo,  not  arising  from  brain 
affection,  is  the  so-called  stomachal  vertigo.  It  is  apt  to  come  on 
in  paroxysms,  sometimes  in  the  middle  of  the  night  or  in  the 
early  morning,  and  is  associated  with  a  dull,  heavy  ache  in  the 
head,  and  with  more  or  less  gastric  disturbance,  often  following 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COPvD.  67 

indiscretion  in  diet.  Yet  the  tongue  may  be  clean,  and  the  digest- 
ive disorder  so  slight  that  it  is  only  by  the  after-symptoms,  by  the 
relief  afforded  by  attention  to  diet,  and  by  remedies  acting  on  the 
digestion,  that  we  clearly  make  out  the  cause  of  the  vertigo. 
Between  the  attacks  the  patient  is  free  from  the  affection ;  though 
there  are  cases  of  more  chronic  kind,  in  which  a  certain  amount  of 
giddiness  is  present  for  long  periods  with  only  comparatively  short 
intervals  of  relief.  Here  food  and  stimulus  are  apt  to  relieve  the 
giddiness,  which  exists  often  with  symptoms  not  of  violent  indi- 
gestion, but  of  delayed  and  slow  digestion,  and  may  become  aggra- 
vated into  a  severe  attack  if  the  stomach  be  for  a  long  time 
empty.  In  the  gastric  vertigo  there  is  no  loss  of  consciousness. 
The  pathology  is  very  obscure.  Woakes*  has  recently  endeavored 
to  establish  a  direct  nervous  communication  between  the  stomach 
and  the  labyrinth  to  explain  the  vertigo. 

Another  form  of  vertigo  of  eccentric  origin  is  that  associated 
with  partial  deafness  or  ringing  in  the  ears.  Again,  there  may  be 
an  affection  of  the  internal  ear,  the  semicircular  canals  of  the  laby- 
rinth especially  being  the  seat  of  an  inflammation,  and  the  vertigo 
set  in  suddenly.  Its  onset  is  apt  to  be  associated  with  vomiting, 
with  suddenly  developed  tinnitus,  with  pain  produced  in  the 
affected  ear  by  the  slightest  noise,  and  with  symptoms  of  apoplexy 
or  a  fainting  condition.  Such  cases,  to  which  Meniere  particularly 
has  called  attention,  at  times  very  speedily  terminate  fatally.  But 
the  acute  seizure,  which  is  by  far  the  most  common  beginning  of 
the  aural  vertigo,  may  leave  behind  giddiness  and  a  persistent 
unsteadiness  in  standing  and  walking,  or  a  reeling  gait,  which, 
with  the  intense  vertigo,  the  vomiting,  the  noises  in  the  ears,  the 
unimpaired  consciousness,  and  the  deafness,  become  very  valuable 
signs  of  Meniere's  disease.  In  some  instances  the  patient  has  a 
tendency  to  turn  to  one  side  or  to  walk  round  and  round  in  a 
circle ;  and  he  is  always  miserable,  although  his  general  health 
suffers  but  little.  Again,  it  may  be  noticed  that  there  is  deafness 
for  certain  groups  of  musical  sounds,  which  Knapp,f  in  his  able 

*  Deafness,  Giddiness,  etc.,  1879. 

f  Archives  of  Ophthalmology  and  Otology,  vol.  ii.  See  also  paper  by  Du- 
play,  Archives  Generates,  Jan.  1872  ;  Hinton,  Guy's  Hospital  Eeports,  1873  ; 
Charcot's  Lectures  ;  Terrier,  "West  Eiding  Reports,  vol.  v.,  and  Clifford 
Allhutt,  St.  George's  Hospital  Eeports,  1877. 


68  MEDICAL    DIAGNOSIS. 

paper  on  the  subject,  accepts  as  proof  that  the  disorder  has 
extended  to  the  cochlea. 

To  return  to  vertigo  connected  with  cerebral  or  cerebro-spinal 
disease.  There  is  a  kind  which  Trousseau  especially  has  de- 
scribed. The  abnormal  sensation  is  very  short  in  its  duration, 
but  severe;  the  patient  momentarily  loses  all  consciousness.  The 
vertigo  recurs  at  uncertain  times :  while  actively  engaged,  some- 
times while  in  bed  and  half  asleep.  The  head  feels  heavy  after 
an  attack,  and  the  mind  is  temporarily  stupefied ;  otherwise  the 
health  is  good.  This  type  of  vertigo  is  dangerous.  It  is  often 
the  precursor  of  epilepsy,  and  after  a  time  becomes  associated  with 
convulsions. 

Another  kind  of  vertigo  is  that  which  arises  from  overwork  of 
the  brain,  and  which,  when  at  all  persistent,  must  make  us  fear 
that  the  organ  has  begun  to  soften.  In  some  instances  the  giddi- 
ness is  the  only  symptom  of  disorder,  and  is  present  for  many 
years,  the  patient  enjoying  otherwise  excellent  health.  I  have 
known  a  number  of  such  instances  in  which  the  tendency  appeared 
to  have  been  inherited.  If  it  do  not  break  out  until  late  in  life  it 
is  a  matter  of  more  serious  concern. 

In  laryngeal  vertigo*  to  which  attention  has  recently  been 
called,  there  is  a  close  connection  with  epileptic  seizures.  The 
chief  symptoms  are  tickling  or  burning  in  the  larynx,  followed 
by  vertigo,  loss  of  consciousness,  and  spasmodic  movements  in  the 
face  and  limbs.  The  larynx  is  healthy ;  but  in  one  case  observed 
by  Sommerbrodt  a  polypus  existed,  the  removal  of  which  cured 
the  affection. 

Besides  headache  and  vertigo,  there  are  various  unnatural  sen- 
sations, such  as  a  feeling  of  momentary  unconsciousness  without 
giddiness ;  a  feeling  within  the  cranium  of  weight,  of  constric- 
tion ;  the  feeling  described  as  a  rush  of  blood  to  the  head ;  ocular 
spectra,  and  other  false  perceptions  of  many  kinds  and  of  every 
gradation.  But  I  shall  do  no  more  than  advert  to  this  subject, 
and  shall  merely,  in  concluding  the  examination  of  the  evidences 
of  deranged  sensation,  consider  some  of  the  morbid  phenomena 
of  the  special  senses,  and  particularly  of  the  sense  of  sight  and  of 
hearing. 

*  G-asquet,  Practitioner  for  August,  1878;  Charcot,  Progres  Medical,  Xo. 
17,  1879. 


"DISEASES    OF    THE    BEAIX    AND    SPINAL    COED.  69 

Derangement  of  Special  Senses. — The  sense  of  vision 
may  be  exalted,  impaired,  or  perverted  in  disorders  of  the  brain, 
whether  organic  or  functional.  It  is  exalted  in  inflammation; 
impaired,  even  totally  lost,  in  softening,  in  tumors,  in  apoplexy, 
and  during  violent  hysterical  attacks  simulating  apoplexy.  Per- 
versions of  the  sense  of  vision  are  more  frequent  than  its  abolition, 
and  probably  more  peculiar  to  cerebral  affections.  They  are  of 
all  kinds, — some  of  great  consequence,  others  of  but  little.  Muscat 
voHtantes,  or  the  delusion  of  spots  and  various  small  objects  float- 
ing before  the  eye,  have  the  latter  significance ;  for  they  may  hap- 
pen in  almost  any  form  of  cerebral  disturbance,  also  in  ansemia, 
in  cardiac  maladies,  in  the  neuroses,  and  in  states  of  nervous  ex- 
haustion. Some  persons  see  but  half  an  object.  This  may  be 
dependent  upon  an  injury  to  the  brain,  or  be  owing  to  some 
purely  local  affection  of  the  eye.  In  the  former  case  there  is  co- 
existing headache,  and  the  mind  generally  shows  signs  of  disorder. 
Double  vision,  unless  connected  with  strabismus  or  with  an  optical 
defect,  is  almost  always  the  result  of  cerebral  disease.  Of  other 
manifestations  of  deranged  sight,  such  as  illusions,  ocular  spectra, 
and  phantasms,  I  shall  only  state  that  they  are  more  common  in 
sick  headache,  and  in  derangement  of  the  mind,  temporary  or  per- 
manent, than  in  recognizable  organic  disease  of  the  brain.  Yet 
in  affections  of  certain  parts  of  the  brain  they  are  often  found ; 
for  in  disease  of  the  posterior  lobes,  as  Hughlings  Jackson  has 
observed,  colored  vision  and  optical  illusions  are  frequent. 

The  appearance  of  the  eye  is  often  of  as  much  significance  as 
the  derangement  of  sight.  Thus,  for  instance,  strabismus  is  of 
usual  occurrence  in  cerebral  ailments.  "We  find  it  during  an 
attack  of  convulsions;  in  meningitis;  in  tumors  at  the  base  of 
the  brain;  in  effusion  into  the  ventricles;  and  previous  to  apo- 
plexy. In  examining  for  strabismus  we  observe  whether  the  eye- 
ball is  turned  inwards  or  outwards.  In  paralysis  of  the  external 
rectus  we  have  ordinarily  an  internal  squint,  in  paralysis  of  the 
internal  rectus  an  external  or  divergent  strabismus.  In  palsy 
of  the  superior  rectus  there  is  inability  to  raise  the  eyeball  in  a 
proper  manner  above  the  horizontal  level ;  not  to  be  able  to  lower 
it  below  indicates  palsy  of  the  inferior  rectus.  Strabismus  con- 
nected with  palsy  of  the  third,  fourth,  or  sixth  nerve  points  for 
the  most  part  to  a  lesion  at  the  base  of  the  brain  in  the  course  of 


70  MEDICAL    DIAGNOSIS. 

the  nerve,  which  is  apt  to  be  ou  the  same  side  as  the  damaged 
muscle.  In  paralysis  of  the  third  nerve  we  have  ptosis,  or  droop 
of  the  upper  eyelid  and  dilatation  of  the  pupil  of  moderate  extent. 

In  some  cerebral  maladies  the  eye  has  a  fixed  stare ;  in  others 
the  eyelids  are  constantly  moving :  but  the  latter  is  a  sign  more 
frequent  in  chorea,  local  spasm,  and  hysteria.  Great  brilliancy  of 
the  eye  is  often  noticed  in  meningitis  and  in  insanity. 

The  pupils  are  variously  affected  by  cerebral  disorders.  We 
find  them  dilated  or  contracted,  sluggish  or  rapidly  reacting,  on 
the  admission  or  exclusion  of  light.  We  observe  a  difference  in 
the  size  of  the  two  pupils,  and  in  their  relative  irritability.  A 
dilatation  of  both  pupils  is  found  in  compression  of  the  brain, 
whatever  its  immediate  cause,  but  especially  in  compression  from 
a  collection  of  fluid  in  the  ventricles  and  in  the  subarachnoid 
spaces ;  the  pupils  likewise  react  very  sluggishly,  sometimes 
hardly  at  all,  under  the  stimulus  of  light,  and  the  retina  appears 
insensible.  A  similar  state,  although  not  carried  to  the  same 
degree,  is  met  with  in  the  congestion  of  the  brain  accompanying 
low  fevers.  We  also  find  dilatation  of  both  pupils  in  chlorosis, 
and  when  the  system  is  under  the  influence  of  belladonna,  and  in 
lesions  of  the  upper  portion  of  the  spinal  cord.  If  the  foot  be 
pricked  or  irritated,  the  pupils  at  once  dilate,  provided  the  iris  be 
uninjured  and  the  sensory  columns  of  the  cord  be  intact.  In 
epileptics  this  reflex  excitability  is  greatly  diminished.* 

Contraction  of  the  pupils  exists  in  the  earlier  stages  of  cerebral 
inflammation.  It  is  then  associated  with  intolerance  of  light, 
which  does  not  occur  if  the  contraction  be  produced  by  narcotism 
or  by  coma.  Contraction  of  the  pupils  happens  also  in  spinal 
diseases. f  One-sided  contraction,  like  one-sided  dilatation  of  the 
pupil,  is  ordinarily  the  result  of  a  one-sided  lesion  of  the  brain ; 
yet  it  may  also  be  owing  to  tumors  at  the  root  of  the  neck. 
Inequality  of  the  pupils  is  also  found  in  affections  of  the  sym- 
pathetic, and  is  apt  then  to  be  associated  with  one-sided  sweating. 
Irritation  of  the  sympathetic  produces  very  great  dilatation. 

But  in  estimating  the  value  of  any  morbid  evidences  furnished 
by  the  state  of  vision  or  the  appearance  of  the  eye,  we  must  make 
allowance  for  the  purely  local  diseases  of  the  organ,  and  exclude 

*  Lawson,  West  Biding  Reports,  vol.  iv. 

f  See  Edinburgh  Medical  Journal,  Dec.  1809. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  71 

them  from  consideration  before  we  draw  conclusions  as  to  the 
condition  of  the  brain.  We  are  greatly  aided  in  this  by  the  use 
of  the  ophthalmoscope,  which  gives  information  not  only  as  to 
many  of  the  mere  visual  disturbances,  but  also  as  to  the  changes 
brought  about  in  the  eye  by  cerebral  affections. 

The  fundus  oculi,  as  revealed  by  the  ophthalmoscope,  presents 
various  lesions,  which,  although  not  pathognomonic  of  any  one 
condition,  furnish  information  of  value  in  locating  more  definitely 
the  particular  disease.  These  lesions  depend  either  on  an  extension 
of  inflammation  of  the  brain  to  the  internal  structures  of  the  eye, 
or  on  the  amount  of  resistance  offered  to  the  circulation  within 
the  cranium.  This  resistance  may  either  arise  from  a  marked 
"  coarse"  lesion,  or  may  make  itself  felt  through  the  sympathetic 
nervous  system. 

"We  should  invariably  examine  with  the  ophthalmoscope  the  eyes 
of  patients  suspected  of  having  disease  of  any  part  of  the  cerebro- 
spinal nervous  system.  Changes  in  the  eye,  indeed,  often  occur 
early  enough  to  be  the  first  certain  sign  of  disease,  and  this,  too, 
without  any  impairment  of  sight;  on  the  other  hand,  lesions  indi- 
cating cerebral  or  other  organic  trouble  have  been  found  in  cases 
in  which  failure  of  sight  only  was  complained  of,  the  cause  being 
unsuspected.  But  particularly  is  the  ophthalmoscope  valuable  in 
enabling  us  to  diagnosticate  organic  from  functional  affections. 

The  changes  in  connection  with  organic  disease  have  been  ob- 
served chiefly  in  the  retina,  the  optic  disk,  and  the  choroid.  And 
in  using  the  ophthalmoscope  for  medical  diagnosis  we  pay  particu- 
lar attention  to  these  structures ;  especially  do  we  note  the  shape  of 
the  disk,  its  color  and  size,  and  the  pigment  around  its  edges,  the 
size  and  appearance  of  the  arteries  and  veins,  whether  diminished, 
enlarged,  or  tortuous,  whether  there  are  exudations  or  hemor- 
rhages in  the  course  of  the  vessels,  and  in  what  part  of  the  eye- 
ground  the  patches  are  most  marked. 

Retinitis  occurs  most  frequently  in  connection  with  intra-cranial 
lesions,  constitutional  syphilis,  and  Bright's  disease.  It  is  char- 
acterized by  a  reddish-gray,  opaque,  swollen,  and  somewhat  hyper- 
semic  optic  disk,  with  an  irregular  and  indistinct  outline,  which 
passes  into  the  retina  without  any  clear  line  of  demarcation.  The 
retina  presents  a  hazy  appearance,  particularly  marked  in  the 
vicinity  of  the  optic  papilla  and  macula  lutea ;  its  arteries  are  but 


72  MEDICAL    DIAGNOSIS. 

slightly  changed  in  appearance,  but  the  veins  are  enlarged,  dark 
in  color,  and  very  tortuous.  Hemorrhagic  extravasations  are 
common;  and  should  we  find  as  an  attendant  upon  retinitis 
miliary  aneurisms  of  the  retina,  they  lead  us  here,  as  indeed 
always,  to  infer  the  same  condition  in  the  vessels  of  the  brain. 

In  syphilitic  retinitis  the  disk  and  retina  are  veiled  by  a  faint, 
bluish-gray  film,  due  to  serous  transudation,  most  marked  along 
the  course  of  the  vessels,  and  shading  off  imperceptibly  into  the 
healthy  retina.  Minute  punctiform  opacities  are  strewn  irregu- 
larly over  the  retina,  and  undergo  rapid  changes,  appearing  and 
disappearing  in  the  course  of  a  few  days.  Galezowski  has  found 
syphilitic  retinitis  and  neuritis  to  be  always  accompanied  by  color- 
blindness. In  patients  who  were  the  victims  of  hereditary  syphilis, 
Mr.  Hutchinson  has  frequently  observed  pigmentary  retinitis. 

The  syphilitic  form  of  retinitis  should  not  be  confounded  with 
that  which  accompanies  Brigld's  disease  of  the  kidney,  and  which 
is  characterized  by  the  formation  on  the  retina  of  brilliant  white 
stellate  spots  in  the  region  of  the  macula  lutea,  and  of  a  broad, 
glistening,  white  mound  encircling  the  optic  disk.  These  spots 
are  constant,  and  are  due  to  a  fatty  degeneration  of  the  connective 
tissue  elements  and  sclerosis  of  the  optic  nerve  fibres.  CEdema  of 
the  retina  is  common ;  and  retinal  hemorrhage  is  also  of  frequent 
occurrence.  The  albuminuric  retinitis  may  occur  when  the  kidney 
changes  are  only  beginning. 

Optic  neuritis,  or  descending  optic  neuritis,  as  it  is  termed, 
results  usually  from  some  disease  about  the  base  of  the  brain,  such 
as  meningitis  or  periostitis.  It  is  also  common  in  tumors  of  the 
brain,  particularly  when  situated  near  the  optic  tract  or  chiasm. 
It  has,  moreover,  been  observed  in  lead  poisoning,  locomotor  ataxia, 
and  other  affections.  In  cases  of  hemiplegia,  Hughlings  Jackson 
has  noted  its  greater  frequency  in  connection  with  left-sided  paraly- 
sis. It  is  almost  invariably  double.  In  lesions  of  the  encephalon 
or  meninges,  Bouchut  thinks  it  is  in  general  more  marked  in  the 
eye  corresponding  to  the  hemisphere  which  is  more  seriously 
affected  ;  Hughlings  Jackson,  however,  denies  the  existence  of  any 
relation  between  the  side  of  the  brain  diseased  and  the  eye  affected. 
The  same  distinguished  observer  tells  us  that  double  optic  neuritis 
is  in  a  large  proportion  of  cases  indicative  of  coarse  disease  of  the 
brain. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  76 

Optic  neuritis  is  very  apt  to  be  confounded  with  "  choked  disk." 
In  truth,  the  distinction  is  not  maintained  by  all  ophthalmologists; 
and  there  are  stages  in  each  which  even  experts  cannot  distinguish 
between.  Moreover,  choked  disk  is  apt  to  be  followed  by  neu- 
ritis. In  both,  hemorrhages  may  exist  on  the  surface  of  the  disk 
or  in  the  surrounding  retina,  and  may  appear  and  disappear,  and 
give  way  to  spots  of  exudation.  The  great  subjective,  distinctive 
symptom,  as  Higgens*  insists,  is  that  in  neuritis  vision  is  almost 
always  impaired,  whilst  no  want  of  sight  is  complained  of  in  choked 
disk.  In  optic  neuritis  there  is  but  little  swelling  of  the  disks, 
and  the  changes  in  them  are  limited  to  capillary  congestion,  and 
some  clouding  of  the  retinal  fibres.  The  inflammation  begins  in 
the  intra-cranial  portion  of  the  nerve  and  extends  along  the  trunk  ; 
in  choked  disk  this  is  not  affected,  but  there  is  an  impediment  to 
the  return  of  blood  from  the  eyeball,  causing  dilated,  tortuous 
veins,  and  subsequently  exudation  of  serum  and  swelling  of  nerve- 
fibres  ;  the  disk  projects,  is  red,  greatly  swollen,  and  not  gray  and 
opaque  and  surrounded  by  a  retina  infiltrated  with  gray  and 
opaque  inflammatory  products,  as  we  find  in  marked  neuritis. 
Any  intra-cranial  affection  which  crowds  the  contents  of  the  skull 
and  obstructs  the  return  of  venous  blood  from  the  eyeball  will 
occasion  the  choked  disk.  But  this  is  probably  not  its  only  cause. 
Accumulations  in  the  lymph-spaces,  and  local  palsy  of  the  sympa- 
thetic, have  been  adduced  by  noted  observers. 

Perineuritis  is  the  name  given  by  Galezowski  to  inflammation 
affecting  chiefly  the  outer  neurilemma.  The  papilla  is  enlarged 
and  prominent,  but  the  exudation  appears  to  be  confined  to  its 
margin.     This  condition  is  very  suggestive  of  meningitis. 

Simple  hypercemia  of  the  disk  may  be  due  to  encephalic  disease, 
to  meningitis,  or  to  Bright's  disease.  A  transient  form  of  hyper- 
emia may  be  seen  in  the  changes  of  cerebral  vascularity  attended 
with  convulsions,  in  affections  of  the  heart,  such  as  aortic  regurgi- 
tation, and  in  Graves'  disease. 

Diseases  of  the  spinal  cord,  as  acute  myelitis  and  spinal  sclerosis, 
frequently  induce  a  congestive  lesion  of  the  optic  papilla,  which 
at  a  later  period  becomes  atrophic.  These  changes  do  not  become 
established  in  cases  of  spinal  disease  which  run  a  short  course, 

*  Guy's  Hospital  Reports,  3d  Series,  vol.  xx.,  1875. 


7-J:  MEDICAL    DIAGNOSIS. 

but  they  slowly  supervene  in  more  chronic  cases.  Intense  conges- 
tion of  the  optic  disks  with  dilated  and  sluggish  pupils  has  been 
specially  observed  in  Pott's  disease  ;*  and  attention  has  been  lately 
called  to  the  coexistence  of  optic  neuritis  and  subacute  transverse 
myelitis,  f 

Anosmia  of  the  disk  and  retina  has  the  same  causes  as  general 
or  local  anaemia.  The  disk  is  pale,  the  retinal  vessels  are  shrunk. 
Hughlings  Jackson  has  described^  a  peculiar  condition  which  he 
observed  in  a  patient  with  epileptiform  convulsions,  and  which  he 
calls  "  epilepsy  of  the  retina."  The  retina  is  entirely  anaemic,  a 
condition  dependent  in  all  probability  upon  contraction  of  the 
retinal  vessels  similar  to  that  which  occurs  in  the  vessels  of  the 
brain  during  an  epileptic  fit. 

Atrophy  of  the  optic  nerve  is  generally  the  result  of  previous 
neuritis,  and  is  apt  to  be  met  with  in  cases  of  cerebral  tumor,  in 
meningitis,  hydrocephalus,  constitutional  syphilis,  sun-stroke,  aud 
after  typhoid  fever.  When  preceded  by  optic  neuritis  the  disk  is 
ill  defined  or  ragged,  otherwise  its  edge  is  apt  to  be  well  defined 
and  the  disk  is  cupped.  In  place  of  its  natural  pink  it  is  white  or 
bluish  white.  Allbutt  has  found§  that  atrophy  of  the  optic  disk 
happens  in  nearly  every  case  of  general  paralysis  of  the  insane, 
beginning  as  a  pink  suffusion  of  the  nerve,  without  much  stasis  or 
exudation,  and  ending  as  simple  white  atrophy, — a  process  which 
he  likens  to  "red  and  white  softening"  of  the  brain.  White 
atrophy  frequently  occurs  in  locomotor  ataxia.  It  may  also  take 
place  in  disseminate  sclerosis  of  the  brain,  and  as  a  secondary 
effect  of  cerebral  hemorrhage.  According  to  Bouchut,||  it  is  never 
seen  in  cases  of  meningitis,  except  when  this  is  a  complication  of 
chronic  meningitis,  an  old  encephalitis,  or  an  old  tumor  of  the 
brain,  and  never  as  a  result  of  spinal  injuries.  Atrophies  of  the 
optic  nerves  are  sometimes  hereditary,  or  happen  from  the  abuse  of 
alcohol  or  tobacco,  or  after  profuse  loss  of  blood. 


*  American  Journal  of  the  Medical  Sciences,  July,  1875. 

f  Erb,  in  Westphal's  Archiv,  Bd.  x. ;  and  Seguin,  Journal  of  Nervous  and 
Mental  Diseases,  April,  1880. 

X  Royal  London  Ophthal.  Hosp.  Rep.,  vol.  iv.  p.  14. 

§  Brit.  Med.  Journ.,  March  14,  18G8  ;  and  on  LTse  of  the  Ophthalmoscope, 
1871. 

||  Diagnostic  des  Maladies  nerveux  par  l'Ophthalmoscopie. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  75 

The  causes  of  choroiditis,  with  the  exception  of  the  syphilitic 
form,  are  obscure.  The  disorder  appears  most  frequently  as  cir- 
cumscribed white  patches  in  the  choroid,  over  which  the  retinal 
vessels  may  be  seen  coursing.  The  syphilitic  form  is  by  far  the 
most  common,  and  is  distinguished  by  the  presence  of  patches  of 
many  colors  at  the  back  of  the  eye,  some  of  a  brilliant  white, 
others  of  darker  tints,  such  as  red  or  brown. 

Tubercles  of  the  choroid  are  a  manifestation  of  the  tubercular 
diathesis.  In  eighteen  cases  of  the  miliary  disease  Cohnheim 
found  tubercles  in  the  choroid  of  one  or  both  eyes  in  every  in- 
stance. They  appear  in  the  form  of  small  circumscribed  spots,  of 
a  pale  rose-red  color  or  grayish-white  tint,  chiefly  in  the  vicinity 
of  the  optic  disk.  The  sight  may  remain  unimpaired.  In  the 
retina  and  choroid  the  existence  of  tubercles  indicates  either  tu- 
bercular meningitis  or  general  tuberculosis.  If,  with  tubercular 
granulations  of  the  choroid,  fever  and  disturbances  of  intellect, 
of  movement,  and  of  sensation  be  present,  the  existence  of  tuber- 
cular meningitis  may  be  determined.  Yet  tubercular  meningitis 
is  revealed  chiefly  by  choked  disk  or  neuritis,  and  even  then  only 
when  it  invades  the  anterior  and  inferior  parts  of  the  encephalon  ; 
for  the  disks  may  be  normal  throughout.  The  changes  are  always 
double,  although,  as  Gowers*  points  out,  more  advanced  on  one 
side  than  on  the  other. 

As  regards  the  sense  of  hearing,  the  same  may  be  said  as  of 
vision.  It,  too,  is  perverted  and  impaired  in  various  cerebral 
affections.  Yet,  to  be  certain  that  the  cause  of  the  difficulty  is 
cerebral,  the  ear  must  first  be  examined  with  reference  to  any 
physical  imperfection ;  and  in  doing  so  we  may  by  means  of  the 
otoscope  get  an  idea  of  the  vascularity  of  the  drum,  and  be  led 
from  this  to  infer  the  condition  of  the  vessels  of  the  brain. 

Great  acuteness  of  hearing  and  intolerance  of  sound  are  gen- 
erally symptoms  of  extreme  nervous  irritability,  or  of  beginning 
cerebral  inflammation.  Deafness  may  be  owing  to  softening  of 
portions  of  the  brain  ;  but  Ferrier  tells  us  that  it  is  not  met  with 
in  destructive  lesions  of  the  cortex.  Deafness  is  also  found  as  a 
temporary  and  by  no  means  unfavorable  symptom  in  the  continued 
fevers.    Imaginary  sounds  and  ringing  noises  in  the  ear,  or  tinnitus 

*  Medical  Ophthalmoscopy,  London,  1879. 


76  MEDICAL    DIAGNOSIS. 

aurium,  are  frequent  accompaniments  of  cerebral  disorders.  But 
the  latter  is  encountered  in  so  many  different  conditions — in  dis- 
eases of  the  cerebral  vessels,  in  congestion  of  the  brain,  in  affec- 
tions of  the  heart,  in  anaemia — that  it  is  a  sign  of  little  moment ; 
and,  in  truth,  its  most  usual  cause  is  local,  namely,  an  accumula- 
tion of  wax  in  the  meatus. 

DERANGED    MOTION. 

The  chief  manifestations  of  deranged  motion  resolve  themselves 
into  the  phenomena  called  paralysis,  ataxia,  tremor,  spasms,  and 
convulsions. 

Paralysis. — When  Ave  speak  of  paralysis,  we  mean  a  loss  of 
muscular  contractility,  and,  as  a  consequence,  of  the  power  of 
motion.  It  is  true,  there  is  also  a  paralysis  of  sensation,  a  com- 
plete anaesthesia,  which  may  be  conjoined  with  the  paralysis  of 
motion ;  but  the  latter  often  happens  alone,  and  is  the  morbid 
state  alluded  to  when  we  use  the  term  paralysis  without  qualifying 
whether  of  sensation  or  of  motion.  A  slight,  incomplete  paralysis 
is  called  "  paresis,"  and  this  term  is  especially  employed  when  the 
loss  of  power  exists  without  demonstrable  organic  change. 

Paralysis  may  be  general,  or  it  may  be  partial.  It  may  affect 
the  majority  of  the  muscles  of  the  frame,  or  be  limited  to  one 
muscle.  It  may  be  strictly  confined  to  one  side,  or  exist  solely  in 
the  lower  half  of  the  body.  It  may  come  on  rapidly,  or  appear 
slowly.  But  under  any  circumstances  it  is  not  a  disease,  but  a 
symptom.  We  must,  in  individual  cases,  therefore,  aim  at  de- 
termining, as  far  as  possible,  its  cause,  before  we  attempt  to 
remedy  the  palsy.  The  causes  which  give  rise  to  paralysis  may 
be  thus  summed  up  : 

Paralysis  due  to  a  lesion  or  any  morbid  condition  of  the  nervous 
centres. — Softening  of  the  central  nervous  textures,  or  any  process 
which  materially  alters  them,  occasions  loss  of  power  in  the  part 
over  which  their  influence  in  health  extends.  The  complete 
paralysis  attending  most  of  the  diseases  of  the  brain  and  of  the 
spinal  cord  belongs,  therefore,  to  this  category. 

But  besides  these  palsies  of  organic  origin  there  are  functional 
palsies,  dependent  upon  what,  so  far  as  we  are  aware,  is  simply 
a  functional  derangement  of  the  great  centres  of  innervation. 
Hysterical  paralysis,  and  that  occurring  after  overwork  or  ex- 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  77 

cesses,  and  so  evidently  from  nervous  exhaustion,  belong  in  this 
category. 

Paralysis  due  to  a  lesion  in  the  course  of  a  nerve. — The  nervous 
force  may  be  properly  generated,  but  the  nerve-fibres  may  be  in- 
capable of  conducting  it.  For  instance,  if  a  nerve  be  wounded  or 
compressed,  paralysis  of  the  muscles  which  it  supplies  takes  place. 
Palsy  from  this  cause  is  local,  is  apt  to  show  marked  nutritive 
changes  in  the  affected  part,  such  as  glossy  fingers  and  swollen 
joints,  and  to  be  associated  with  pain.  . 

Paralysis  due  to  an  affection  of  the  nerves  at  their  extremities. — 
A  paralysis  originating  at  the  periphery  of  a  nerve  is  a  rare  com- 
plaint. Yet  we  meet  every  now  and  then  with  illustrations  of 
such  a  disorder :  for  example,  the  palsy  resulting  from  exposure  to 
cold.  Peripheral  palsies  lead  quickly  to  atrophy  of  the  muscles. 
They  are,  from  their  very  nature,  local,  and  commonly  remain  so. 

Paralysis  due  to  reflex  action. — Here  the  paralysis  is  produced 
through  the  medium  of  the  great  seat  of  the  reflex  system,  the 
spinal  cord,  which  reflects  the  irritation  communicated  to  it  to 
parts  healthy  in  themselves.  At  all  events,  cases  are  from  time 
to  time  met  with  which  admit  of  no  other  explanation.  How 
else  can  excitation  of  the  dental  nerves  in  teething  children,  or 
disorders  of  the  intestines  both  in  adults  and  in  children,  or  dis- 
ease of  the  bladder,  urethra,  prepuce,  uterus,  lungs,  or  pleura,  or 
irritation  of  the  nerves  of  the  skin,  occasion  paralysis?  or  how 
else  can  a  wound  of  a  nerve  on  one  side  of  the  body  lead  to  palsy 
on  the  other?  The  most  common  cause  of  the  affection  is  periph- 
eral irritation.  It  is  now  held  by  some,  by  Leyden  in  particular, 
that  a  true  neuritis,  or  at  least  a  high  degree  of  congestion,  travels 
along  the  nerves  until  it  reaches  the  cord.  Hammond  regards  the 
lesion  as  an  altered  condition  of  the  vessels  of  the  cord,  resulting 
in  anaemia.  But  the  question  as  to  the  state  of  the  nerve-centres 
in  reflex  paralysis,  and  how  they  become  implicated,  is  still  un- 
settled. 

Paralysis  brought  on  by  reflex  action  is  rarely  of  long  duration. 
It  develops  gradually,  is  increased  or  diminished  as  the  causes 
which  produce  it  increase  or  diminish,  and,  as  a  rule,  soon  dis- 
appears after  the  source  of  disturbance  is  removed.  It  may  affect 
almost  any  part  of  the  body,  and  assumes  often  the  paraplegic 
form. 


78  MEDICAL    DIAGNOSIS. 

Paralysis  due  to  serious  interference  with  the  circulation. — This 
kind  of  palsy  is  observed  if  the  principal  artery  of  a  part  be  ob- 
literated. But  it  is  not  often  encountered,  and,  when  met  with,  is 
not  unusually  found  to  be  connected  with  gangrene  of  the  para- 
lyzed part.  It  is  sometimes  noticed  as  a  transient  phenomenon 
after  the  ligation  of  a  large  artery.  If  the  vascular  supply  of 
the  brain  be  interfered  with  by  the  occlusion  of  a  vessel,  whether 
by  embolism  or  by  thrombosis,  the  hemiplegia  that  results  is  more 
permanent  and  very  marked.  Among  the  circulatory  disturbances 
that  may  lead  to  palsies  we  must  not  forget  to  look  for  the  altered 
blood-tension  produced  by  disease  of  the  heart,  and  the  degenera- 
tion of  the  vessels  caused  by  Bright's  disease. 

Paralysis  due  to  a  morbid  state  of  the  muscles. — Any  process 
which  materially  impairs  the  normal  structure  of  muscular  tissue 
will  entail  loss  of  muscular  power;  but,  in  point  of  fact,  the  dis- 
eases which  commonly  occasion  this  form  of  paralysis  (if  it  be 
correct  to  call  that  paralysis  in  which  the  nervous  system  is  not  to 
appearance  primarily  or  particularly  concerned)  are  certain  forms 
of  rheumatic  palsy  and  of  muscular  atrophy,  and  especially  the 
progressive  muscular  atrophy  connected  with  fatty  degeneration. 

Paralysis  due  to  the  -presence  of  poisons  in  the  system. — The 
toxical  effects  of  lead,  arsenic,  mercury,  alcohol,  and  of  sulphuret 
of  carbon,  may  exhibit  themselves  by  producing  palsy.  Malarial 
poisons,  and  poisons  formed  in  the  system,  such  as  that  of  rheu- 
matism or  of  gout,  may  act  in  the  same  way.  The  former  occa- 
sion that  singular  "  intermittent  paralysis"  which  may  come  on 
either  as  one  of  the  phenomena  of  a  fit  of  ague,  or  as  an  ap- 
parently independent  complaint,  which  assumes  either  the  quo- 
tidian or  the  tertian  type,  and  in  which  both  sensation  and  motion 
may  be  affected.  How  any  of  these  poisons  operate,  whether  by 
interfering  with  the  nutrition  of  the  nervous  centres  and  weaken- 
ing their  generating  force,  or  by  enfeebling  the  conducting  power 
of  the  nerves,  is  unknown.  The  palsies  coming  under  this  head, 
being,  as  it  were,  functional,  are  not  ordinarily  intractable.  Those 
due  to  malaria  yield  speedily  to  decided  doses  of  quinia.  Similar 
to  the  palsies  of  poisons  and  certain  cachexias  are  those  produced 
by  changes  in  the  blood  after  acute  diseases.  Yet  actual  struc- 
tural changes  have  been  found  in  these  paralyses  of  blood  origin. 

In  the  parts  affected  with  paralysis,  the  nutrition  and  secretion 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  79 

are  disturbed  and  the  circulation  is  sluggish.  They  are  frequently 
swollen  and  cedematous,  the  pulse  is  weaker  than  in  the  sound 
members,  and  the  sensation  is  impaired.  The  nails  grow  slowly,* 
so  do  the  hairs;  the  perspiration  is  defective;  the  skin  feels  cold, 
is  prone  to  break  from  the  effect  of  pressure,  or  even  independ- 
ently of  it,  and  the  ulcers,  if  they  heal  at  all,  heal  but  tardily. 
The  condition  of  the  muscles  is  various.  In  some  cases  they  are 
completely  relaxed,  in  others  rigid;  at  times  they  become  agitated 
with  convulsive  movements.  These  phenomena  are  most  evident 
in  palsies  of  organic  origin,  especially  in  those  dependent  upon 
a  brain-lesion,  and  in  those  due  to  disease  of  the  spinal  cord  in 
which  anaesthesia  is  present.  Where  hyperassthesia  occurs,  the 
increased  sensibility  is  attended  with  a  larger  supply  of  blood  and 
a  higher  temperature  than  normal. 

Having  alluded  to  some  of  the  general  traits  and  to  the  causes 
of  paralysis,  let  us  examine  its  chief  varieties  with  reference  to 
their  significance  and  diagnosis.  In  so  doing,  it  will  be  con- 
venient to  be  guided  by  their  marked  coarse  features  rather  than 
by  the  presumed  origin. 

But  before  inspecting  these  we  shall  briefly  inquire  into  the 
mode  in  which  palsies  are  investigated  at  the  bedside.  We  ascer- 
tain, of  course,  the  size,  appearance,  and  feel  of  the  stricken  part ; 
take  notice  of  its  growth  and  of  the  nutritive  changes,  such  as 
alterations  in  look  and  action  of  the  skin,  the  presence  on  it  of 
eruptions  and  of  breaks,  the  state  of  the  cutaneous  circulation,  of 
the  nails,  the  hair,  and  the  joints.  Then  we  test  the  sensibility  to 
contact,  to  tickling,  to  pinching,  to  heat  and  cold;  measure  the 
tactile  sense  by  the  sesthesiorneter ;  and  carefully  note  any  reflex 
movements  that  may  be  produced  in  the  apparently  lifeless  limb 
by  touching  with  a  piece  of  heated  metal  or  by  tickling  parts 
usually  very  sensitive, — such  as  the  sole  of  the  foot, — or  by  smartly 
tapping  groups  of  muscles.  We  next,  where  minuteness  of  inves- 
tigation is  desirable,  ascertain  the  temperature  by  a  surface  ther- 

*  This  condition  of  the  nails,  spoken  of  in  former  editions,  has  been  of  late 
fully  investigated  by  Dr.  Weir  Mitchell  (Injuries  of  Nerves,  and  their  Con- 
sequences), who  states  that  the  nail-growth  is  abolished  in  recent  cerebral 
palsies,  and  that  its  renewal  may  be  made  an  element  of  prognosis  as  show- 
ing impending  recovery.  In  the  diagnosis  between  functional  and  organic 
palsies,  the  study  of  the  nail-growth  comes,  as  Dr.  Mitchell  points  out,  com- 
pletely into  play,  and  is  likely  to  be  of  value. 


80  MEDICAL    DIAGNOSIS. 

raometer,  or  a  thermo-electric  apparatus;  and  pass  on  to  a  thorough 
study  of  the  condition  of  the  muscles  and  of  muscular  motion. 

Xow,  in  examining  the  muscles  we  do  not  find  them  much 
wasted, — not  more  than  their  disuse  will  account  for.  This  is 
certainly  true  in  palsies  of  cerebral  origin.  Moreover,  we  gen- 
erally observe  them  to  be  flaccid,  rigidity,  especially  early  rigidity, 
being  rare;  but  a  stiffening,  associated  with  pain  in  attempts  to 
straighten  the  contracted  part,  is  not  so  rare  where  the  palsies  have 
been  of  longer  standing,  and  has  had,  as  we  shall  see  presently,  a 
special  meaning  attached  to  it.  Then,  irrespective  of  the  condition 
of  flaccidity  or  stiffening,  we  must  look  into  the  degree  of  abolition 
of  muscular  motion,  carefully  contrasting  it,  when  one-sided,  as 
indeed  we  must  all  the  phenomena  under  investigation,  with  the 
movements  of  the  other  side.  Is  the  motion  completely  abolished, 
or  only  impaired  ?  what  muscles  particularly  are  affected  ?  are 
concerted  movements  possible?  and  how  is  the  gait,  if  we  are 
testing  the  muscles  of  the  legs,  during  these  movements '?  More- 
over, what  amount  of  muscular  effort  is  required  to  overcome 
special  resistance  ?  how  is  the  balancing  power  ?  and  how  are 
delicate  and  combined  movements  executed  when  the  eyesight  is 
withdrawn  ?  \Yhen  the  power  in  the  arms  is  only  impaired,  not 
lost,  we  ascertain  the  degree  roughly  by  the  strength  of  the  grasp. 
But  we  can  do  so  accurately  by  a  dynamometer.  Of  these,  the 
one  I  like  best  and  use  most  is  that  of  Mathieu  (Fig.  7),  consisting 

Fig.  7. 


of  a  steel  ring,  slightly  elastic,  which  is  pressed  firmly  in  the  hand 
and  records  the  pressure. 

But  the  most  valuable  agent  to  judge  of  the  state  of  the  mus- 
cles is  electricity,  especially  the  forms  of  it  known  as  the  induced 
current,  or  "  faradization,"  and  the  constant  current,  or  "galvan- 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  81 

ism."  For  a  time  the  two  were  used  indiscriminately  to  test  the 
contractility  of  a  muscle,  but  of  late  the  action  of  each  has  been 
separately  studied.  Since  Marshall  Hall  enunciated  the  doctrine 
that  when  a  muscle  is  separated  from  the  influence  of  the  cord  its 
power  of  electric  irritability  and  the  electro-muscular  contractility 
cease,  we  have  learned  to  understand  that  in  destructive  diseases 
of  the  cord  diminished  or  lost  electro-muscular  contractility  is  a 
most  valuable  sign.  But  we  do  not  find  in  spinal  paralysis  all 
the  muscles  necessarily  affected :  those  supplied  by  nerves  having 
their  origin  in  healthy  spinal  texture  preserve  their  normal  irrita- 
bility. In  truth,  if  the  uninjured  part  of  the  cord  has  become 
irritated,  or  more  vascular,  the  muscles  having  a  nervous  con- 
nection with  it  may  show  increased  susceptibility  to  the  electric 
current,  and  more  energetic  contraction.  Again,  it  would  not  be 
right  to  infer  that  diminished  electro-muscular  contractility  is 
always  due  to  a  spinal  lesion.  We  find  it  when  the  nerve  itself 
is  injured,  and  it  then  comes  on  very  quickly ;  when  there  is  a  mere 
local  change  in  the  muscular  texture  of  the  helpless  part;  and  as 
the  result  of  certain  poisons,  as  of  opium,  lead,  rheumatism,  or 
other  blood-poisons,  which  lower  the  power  of  nerve,  of  muscle,  or 
of  nerve-centre.  We  find  it  also  when  there  has  been  long  disuse 
of  a  part,  as  in  old  cases  of  hysterical  palsy,  and  even  of  cerebral 
palsy.  But  under  these  circumstances  it  is  temporary,  not  perma- 
nent, as  in  spinal  paralysis ;  for  using  the  battery  for  a  few  days 
makes  the  greatest  change  in  the  electro-muscular  contractility. 
Lastly,  there  are  certain  cases  of  spinal  paraplegia,  farther  on 
more  particularly  to  be  studied,  and  of  impaired  power  with  spinal 
lesions,  as  in  locomotor  ataxia,  in  which  the  electro-muscular  con- 
tractility is  not  markedly  damaged. 

We  now  have  to  consider  the  cases  of  palsy  in  which  the 
electro-muscular  contractility  is  normal.  And  here  we  find, 
speaking  in  general  terms,  all  the  forms  due  to  brain  disease. 
The. palsied  limb  may  have  its  muscles  more  powerfully  con- 
vulsed by  a  current  of  the  same  intensity  than  those  of  the  sound 
side,  and  then  we  may  infer,  as  Todd*  and  Althausf  have  shown, 
that  the  paralysis  is  due  to  brain  disease  of  an  irritative  character. 

The  remarks  made  are  based  on  the  effects  obtained  by  the 


*  Clinical  Lectures  on  the  Nervous  System.  f  Medical  Electricity. 

6 


82  MEDICAL     DIAGNOSIS. 

induced  current,  or  faradization.  A  continuous  current  may  give 
the  same  or  it  may  give  different  results;  the  muscles  of  a  palsied 
part  may  respond  actively  to  galvanization  and  not  at  all  to  fara- 
dization. This  has  been  observed,  for  instance,  in  traumatic 
nerve-lesions,*  in  lead  palsy,  |  and  in  other  affections.  But  it  is 
far  from  settled  to  what  degree  these  differences  may  be  made 
available  for  diagnostic  purposes.  Again,  we  may  find  dissimi- 
larities by  interrupting  the  galvanic  current,  and  these  may  vary 
whether  the  current  be  rapidly  or  slowly  broken.  Thus,  Russell 
ReynoldsJ  has  shown  us  that  in  certain  instances  of  facial  palsy 
from  exposure  to  cold,  or  in  paralysis  of  the  limbs  from  the  same 
cause,  or  in  lead  palsy,  the  muscles  act  as  little  under  the  rapidly 
interrupted  galvanic  current  as  under  faradization ;  but  if  the 
galvanic  current  be  slowly  interrupted,  they  exhibit  a  greater 
amount  of  irritability  than  do  the  healthy  muscles.  In  these 
cases  it  is  found  that  the  muscles  are  primarily  affected,  and  the 
application  of  slowly  interrupted  galvanism  is  rapidly  of.  much 
service.  And  it  may  be  well  in  all  cases  of  palsy,  whatever  be 
the  form  of  battery  employed,  to  note  the  differences  in  the  con- 
traction of  the  muscles  produced  by  slow  or  rapid  interruptions. 

In  making  investigations  to  test  the  responsive  power  of  muscle, 
we  must  always  begin  with  a  weak  current;  and  we  place  the 
moistened  sponges  of  the  electrodes  over  the  muscle  or  group  of 
muscles  to  be  examined,  comparing  them  then  with  the  action  of 
those  on  the  healthy  side.  Some  difference  is  produced  by  placing 
the  one  or  other  of  the  sponges  over  the  seat  of  chief  nerve-supply 
in  the  muscle;  and  to  ascertain  readily  the  nerve-points  has  been 
recently  made  a  matter  of  much  study,  but  as  yet  with  no  definite 
clinical  result  in  diagnosis.  Still,  it  is  best  to  select  these  points 
as  nearly  as  possible,  since  they  correspond  with  the  entrance  of  the 
motor  nerves  into  the  muscles,  and  experience  proves  that  from 
these  motor  points,  determined  with  infinite  care  and  labor  by 
Ziemssen,^  the  readiest  control  of  the  muscles  is  obtained.  When 
the  muscles  react  under  electricity  the  contraction  is  felt,  and  the 

*  By  Ziemssen,  Erb,  Eulenberg. 
f  See  Kosenthal's  Nervenkrankheiten,  1875. 
+  Clinical  Uses  of  Electricity,  London,  1873. 

\  Die  Electricitat  in  der  Medicin  ;  also  Tibbits's  Handbook  of  Electricity, 
London,  1877. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  83 

"electro-muscular  sensibility"  is  more  decided  the  stronger  the 
contraction.  Hence  we  almost  always  find  increased  electro-mus- 
cular contractility  with  increased  electro-muscular  sensibility.  But 
the  latter  may  exist  alone,  as  we  mostly  observe  in  myalgias.  On 
the  other  hand,  the  relationship  between  diminished  contractility 
and  sensibility  may  be  changed,  as  we  find,  for  instance,  in  the 
striking  want  of  sensibility  to  the  current  in  hysterical  paralysis. 
The  electric  reactions  of  the  skin,  so  well  tested  by  a  metallic 
brush,  as  a  rule  go  hand-in-hand  with  the  reactions  of  the  muscles, 
increase  in  sensitiveness  with  them,  decrease  with  them. 

Such  are  the  chief  facts  with  reference  to  the  diagnostic  appli- 
cations of  electricity  in  paralysis.  But  there  is  another  mode  of 
investigation  we  constantly  bring  into  use,  one  also  in  which  the 
action  of  the  muscles  particularly  gives  us  valuable  information 
concerning  the  state  of  the  nervous  system, — the  testing  of  the 
reflex  excitability.  By  irritating  or  stimulating  the  skin  or  tendons, 
by  tickling  the  sole  of  the  foot  or  the  palm  of  the  hand,  we  obtain 
the  well-known  involuntary  movements  which  throw  much  light 
on  the  condition  of  the  nerve-centres,  especially  in  the  spinal  cord. 
We  find  the  reflex  excitability  diminished  in  disease  of  the  gray 
substance  of  the  cord,  in  disease  of  the  sensory  root-fibres,  which 
thus  become  incapable  of  conducting  the  impression,  and  in  disease 
of  the  motor  fibres,  which  fail  to  impart  the  motor  impulse.  In 
the  latter  case  there  is  coexisting  paralysis  of  motion;  in  the 
second,  anaesthesia.  Increase  of  reflex  excitability,  producing 
twitching  or  even  violent  irregular  movement  on  very  slight 
stimulation,  is  found  in  all  irritative  lesions  which  have  increased 
the  excitability  of  the  gray  substance,  as  when  this  is  disturbed 
by  inflammation,  or  compressed  by  a  tumor,  or  heightened  by  cer- 
tain drugs,  such  as  strychnia.  Increase  of  reflex  excitability  is 
also  found  in  parts  below  a  lesion,  when  this  is  so  complete  that  it 
cuts  oif  the  healthy  gray  substance  of  the  cord  from  the  controlling 
action  of  the  brain,  as  in  large  tumors  and  spinal  apoplexies. 

And  as  regards  the  action  of  the  brain,  there  are  instances  in 
which,  if  all  power  of  appreciating  impressions  be  lost,  as  in  over- 
whelming cerebral  apoplexies,  reflex  action  may  be  everywhere 
suspended.  On  the  other  hand,  we  find  signs  of  reflex  action 
manifesting  themselves  by  irritation  transferred  from  diseased  to 
healthy  parts  of  the  brain,  producing  spasms  or  palsy  phenomena, 


84  MEDICAL    DIAGNOSIS. 

alluded  to  in  the  sketch  of  the  scat  of  cerebral  lesions.  Xor  must 
Ave  from  a  clinical  point  of  view  omit  to  mention  the  reflex  actions 
excited  in  other  parts  of  the  body,  as  from  diseases  of  bones  and 
joints,  or  the  muscular  contractions  in  the  legs  during  catheteriza- 
tion or  in  colics.  Here,  although  the  primary  irritation  is  not  in 
the  skin,  the  seat  of  the  perverted  reflex  action  is  entirely  in  the 
gray  substance  of  the  cord. 

Another  class  of  reflex  phenomena  are  those  connected  with 
the  tendons.  The  tendon  of  the  patella  is  the  one  most  readily 
studied;  and  if,  as  Westphal*  and  Erb  have  recently  taught  us 
to  do,  we  strike  abruptly  the  tendon  of  the  patella  just  below  the 
knee-cap,  after  rendering  the  ligamentum  patella?  tense  by  flexing 
the  knee  at  a  right  angle  while  one  knee-joint  rests  upon  the 
other,  a  sudden  contraction  takes  place  in  the  quadriceps  femoris 
muscle,  and  the  foot  is  jerked  upwards.  When  very  slight  it  is 
most  readily  elicited  by  a  tap  with  the  percussion  hammer.  This 
knee  phenomenon  is  found  in  health,  and  has  been  markedly 
observed  in  tumors  of  the  brain,  in  cerebro-spinal  sclerosis,  in 
lateral  sclerosis.  But  it  is  absent  in  locomotor  ataxia,  and  is  not 
to  be  found  even  at  an  extremely  early  stage  of  this  affection. 

Very  similar  to  the  knee  phenomenon  is  the  foot  phenomenon,  or 
"ankle  clonus,"  although  its  reflex  character  is  much  more  doubt- 
ful. Gowers,f  indeed,  has  made  it  likely  that  it  is  largely  due  to 
an  exaggerated  irritability  of  the  muscles.  It  is  produced  if  the 
foot  be  suddenly  brought  into  complete  flexion  by  the  hand  pressed 
against  the  sole,  and  still  more  readily  if  subsequently  the  tendo 
Achillis  be  quickly  tapped.  A  kind  of  convulsive  shaking  of 
the  foot  results,  dependent  on  alternate  contraction  and  relaxation 
of  the  anterior  tibial  and  calf  muscles.  Ankle  clonus  is  at  times, 
though  not  often,  observed  in  healthy  persons;  in  lateral  sclerosis 
it  is  developed  to  an  extraordinary  degree.  Indeed,  it  is  in  excess 
in  the  class  of  affections  in  which  the  knee  reflex  is  excessive. 
"When  produced  by  sudden  passive  tension  alone  of  the  muscle,  it 
is  always  indicative  of  structural  change  in  the  spinal  cord. J 

There  are  other  reflexes  which  we  may  mention  by  which  we 
ascertain  the  condition  of  the  spinal  cord  in  its  different  parts, 

*  Archiv  fur  Psychiatrie,  Bd.  v.,  1875. 

f  Medico-Chirurg.  Transact.,  1879. 

X  Gowers,  Diagnosis  of  Diseases  of  the  Spinal  Cord,  London,  1880. 


DISEASES    OF    THE    BRAIX    AND    SPIXAL    COED.  85 

such  as  the  cremaster  reflex,  the  drawing  up  of  the  testicle  excited 
by  stimulating  the  front  and  inner  side  of  the  thigh,  and  origi- 
nating in  the  cord  at  a  point  between  the  first  and  second  lumbar 
pairs ;  the  abdominal  reflex,  a  contraction  in  the  abdominal  walls 
caused  by  scratching  the  skin  on  the  side  of  the  abdomen,  and  de- 
pending on  the  action  of  the  cord  from  the  eighth  to  the  twelfth 
dorsal  nerve;  and  the  epigastric  reflex,  an  epigastric  dimpling 
produced  by  stimulating  the  side  of  the  chest  in  the  fifth  or  sixth 
intercostal  space,  and  indicating  the  state  of  the  cord  from  the 
fourth  to  the  seventh  pair  of  dorsal  nerves.  In  disease  these 
superficial  reflexes  are  often  absent.  Thus,  disease  of  one  cere- 
bral hemisphere  diminishes  or  destroys  them  on  the  other  side,  the 
paralyzed  side  of  the  body. 

All  these  remarks  tell  us  how  to  examine  paralysis.  Having 
now  studied  the  modes  in  which  this  is  investigated,  I  shall 
merely  recall  that  to  find  out  the  cause  of  the  difficulty  we  have 
to  take  into  account  the  history  of  the  case,  and  the  attending 
symptoms,  nervous  and  otherwise;  and  in  eliciting  these  we  should 
never  forget  to  bring  out  prominently  those  shown  us  by  the 
ophthalmoscope,  and  by  examination  of  the  urine  and  the  heart. 

Let  us  return  to  the  clinical  study  of  palsies. 

HEMIPLEGIA. 

We  shall  first  consider  that  form  which  almost  always  results 
from  brain  disease, — hemiplegia,  or  one-sided  palsy.  This  state 
of  things  may  affect  all  the  voluntary  muscles  on  one  side  of  the 
body;  but  it  generally  exists  only  in  those  of  the  limbs  and  face; 
the  eye,  neck,  and  trunk  muscles  escape.  Neither  the  legs  nor  the 
arms  can  move,  and  the  muscles  of  the  face  on  the  side  correspond- 
ing to  the  paralyzed  limbs  are  motionless.  The  cheek  hangs ;  the 
mouth  is  drawn  toward  the  healthy  side,  because  the  muscles  on 
the  other  are  powerless  to  resist ;  the  tongue,  when  protruded,  is 
ordinarily  slowly  pushed  out  toward  the  palsied  side ;  the  articu- 
lation is  imperfect. 

But  the  rule  with  respect  to  the  face  being  paralyzed  on  the 
same  side  as  the  rest  of  the  body  has  its  exceptions.  Indeed, 
when  we  reflect  that  the  nerves  which  supply  the  facial  muscles 
are  given  off  above  the  point  of  decussation  of  the  nervous  fibres 
in  the  cord,  it  seems  perplexing  that  it  should  be  a  rule  at  all. 


86  MEDICAL    DIAGNOSIS. 

The  solution  of  the  question  lies  in  the  crossing  of  the  facial 
nerves.  Should,  then,  the  lesion  be  seated  in  the  brain  above  this 
crossing,  both  face  and  body  are  paralyzed  on  the  side  opposite  to 
the  diseased  spot.  Should,  however,  the  lesion  involve  the  facial 
nerve-fibres  at  a  point  below  or  after  the  decussation,  there  will 
be  paralysis  of  the  face  on  one  side,  and  of  the  limbs  on  the  other, 
the  facial  palsy  being  direct,  and  that  of  the  body  being  crossed. 

Now,  according  to  Gubler,*  who  has  investigated  the  intricate 
subject  with  much  skill,  this  cross  paralysis  is  always  indicative 
of  a  lesion  of  the  pons  Varolii,  close  to  which  the  facial  nerves 
originate,  and  through  which  the  nerve-fibres  for  the  limbs  pass 
before  they  decussate  lower  down.  But  in  adopting  this  con- 
clusion we  must  always  remember  that  there  are  rare  cases  of 
"alternating  hemiplegia"  due  to  a  combination  of  several  lesions, 
one  affecting  a  cerebral  lobe  on  one  side  and  the  facial  nerve  on 
the  other.  Even  when  the  lesion  is  unilateral,  we  may  meet  with 
exceptional  cases ;  and,  as  Bastianf  forcibly  points  out,  the  lesion 
may  be  situated  in  the  pons,  the  palsy  of  face  and  limbs  not  being 
alternate,  provided  the  disease  occur  in  the  upper  or  anterior  part 
of  one  lateral  half,  implicating  the  fibres  of  the  facial  above  their 
sites  of  decussation.  With  reference  to  the  other  cerebral  nerves, 
should  we  find  any  of  them  paralyzed  on  one  side  and  the  body 
on  the  other,  we  shall  generally  be  correct  in  assuming  that  the 
palsy  is  not  due  to  disease  on  both  sides  of  the  brain,  but  is  rather 
a  disturbance  of  the  affected  nerve  near  its  origin  or  in  its  course, 
and  on  the  side  on  which  the  brain  is  injured,  while  the  paralysis 
of  the  limbs  is  on  the  opposite  side.! 

Hemiplegia,  as  already  stated,  results,  in  the  vast  majority  of 
instances,  from  cerebral  disease.  Hence  we  find  it  commonly 
associated  with  disordered  mental  powers,  and  other  signs  of  a 
brain-lesion.  Hemiplegia  caused  by  an  affection  of  one-half  of 
the  spinal  cord,  near  its  commencement,  is  not  combined  with 

*  De  l'hemiplegie  alterne  envisagee  comme  signe  de  lesion  de  la  protube- 
rance annulaire,  Gaz.  Hebdorn.,  1856,  1859. 

f  Paralysis  from  Brain  Disease,  1875. 

$  Minute  anatomical  researcbes,  particularly  those  of  Lockhart  Clarke,  have 
removed  much  of  the  obscurity  in  attempting  to  explain  these  double  palsies, 
as  well  as  the  dissimilar  manner  in  which  the  facial  nerve  is  atFected.  Con- 
necting nuclei  on  the  floor  of  the  fourth  ventricle  and  elsewhere  have  been 
traced.     (See  Philosophical  Transactions,  Part  I.,  18G8.) 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  87 

a  decay  of  the  mental  faculties,  but  the  muscles  of  the  chest  and 
abdomen  are  involved  in  the  paralysis,  which  they  are  not  in 
cerebral  hemiplegia,  unless  the  lesion  be  very  extensive.  Then 
in  spinal  hemiplegia  there  is  coexisting  anaesthesia,  as  Brown- 
Sequard  has  shown,  on  the  side  opposite  to  the  lesion  and  the 
muscular  palsy ;  the  palsied  limb  gives  evidences  of  vaso-motor 
paralysis,  has  a  higher  temperature,  and  is  hypersesthetic ;  the 
umbilicus  is  with,  every  act  of  inspiration  drawn  toward  the 
sound  side ;  and,  according  to  Romberg,  spinal  hemiplegia  is  more 
persistent  in  the  leg  than  it  is  in  the  arm.  We  possess  a  further 
test  in  electricity :  unlike  what  happens  in  cerebral  paralysis,  the 
electro-muscular  contractility  is  greatly  lessened  or  is  lost.  Spinal 
hemiplegia,  or  "  heniiparaplegia,"  as  it  is  more  often  called  if  the 
lesion  be  low  down,  occurs  from  injuries,  tumors,  syphilitic  disease 
of  the  cord,  and  localized  sclerosis.* 

But  supposing  that  we  have  settled  the  hemiplegia  to  be  cere- 
bral, the  points  next  to  be  investigated  are,  where  is  the  lesion 
situated?  and  what  is  its  nature?  Now,  the  former  question, 
concerning  the  anatomical  diagnosis,  may  be  answered  in  a  general 
way  by  stating  that  the  disease  is  on  the  side  opposite  to  the  palsy, 
if  the  lesion,  as  it  almost  always  is,  be  seated  above  the  point  of 
decussation  of  the  pyramidal  columns  of  the  medulla ;  for  a  lesion 
below  the  decussation  gives  rise  to  palsy  on  the  same  side,  and  a 
lesion  on  a  level  with  the  decussation,  to  double- sided  palsy. 
Furthermore,  we  may  reasonably  conclude  that  the  morbid  process 
has  affected  the  corpus  striatum,  if  motion  be  seriously  impaired ; 
or  has  attacked  the  optic  thalamus,  if  there  be  less  marked 
motor  palsy,  early  tonic  and  clonic  spasms  in  the  palsied  limbs  or 
about  the  face  and  neck,  and  decided  difference  in  temperature 
between  the  limbs  on  the  paralyzed  and  on  the  sound  side,f  and 
some  paralysis  of  sensation ;  yet,  in  point  of  fact,  so  intimate  is 
the  union  between  the  corpus  and  the  thalamus  that  one  is  hardly 
ever  much  disorganized  without  the  other  being  drawn  into  the 
disease. 

The  nearer  the  lesion  to  the  surface,  the  more  marked  are  the 
mental  phenomena,  the  greater  is  the  tendency  to  spasms  in  the 

*  Cases  by  Charcot  and  Gombault,  and  by  Troisier,  Archives  de  Physio- 
logie,  1878. 

•j-  Bastian,  Paralysis  from  Brain  Disease,  1875. 


88  MEDICAL    DIAGNOSIS. 

limbs,  but  the  more  incomplete  the  palsy;  and  the  farther  the 
disease  extends  toward  the  corpus  striatum,  the  more  thorough 
does  the  paralysis  of  motion  become.  We  may  further  distinguish 
the  palsy  which  ensues  from  that  caused  by  an  affection  lower 
down,  as  of  the  pons  Varolii,  by  observing  that,  besides  the  pe- 
culiar crossed  paralysis  of  the  face  and  limbs  which  so  often  hap- 
pens in  this,  and  which  has  been  above  described,  we  find  extreme 
coldness  of  that  side  of  the  body  which  is  to  become  paralyzed 
after  a  time;  also  giddiness  and  a  tendency  to  vomit ;  proneness 
to  cry  or  laugh  without  sufficient  cause;  jerkings  of  the  muscles 
of  the  face  on  the  side  opposite  to  the  injury;  sensations  of  tick- 
lings in  the  face;  and  one-sided  facial  anaesthesia,  with  a  loss  of 
sense  of  taste  on  the  corresponding  side,  though  with  unimpaired 
motion  of  the  tongue.  Should  we  encounter  paralysis  of  sensi- 
bility and  motion  on  one  side  of  the  body,  and  both  sides  of  the 
face  be  palsied  as  to  motion  and  sensation,  should  the  recti  muscles 
of  the  eye  be  paralyzed,  and  taste  be  lost  over  the  anterior  part  of 
the  tongue,  we  may  infer  that  the  injury  is  seated  rather  above  the 
lower  portions  of  the  pons,  and  affects  the  spot  where  the  facial 
nerve  and  part  of  the  trigeminal  cross.* 

In  lesions  involving  the  central  parts  of  the  pons,  paralysis, 
mostly  unequal,  of  both  sides  of  the  body,  with  impaired  sensa- 
tion, irregular  facial  palsy,  difficulty  in  deglutition  and  articula- 
tion, is  the  rule.  Lesions  of  the  lower  and  inner  part  of  the  crus 
Hermann  Weber  has  taught  us  to  recognize  by  an  alternate  pa- 
ralysis, in  which  the  third  nerve  is  palsied  on  the  side  of  the  brain 
affected,  showing  us  want  of  action  of  the  muscles  of  the  eyeball, 
except  the  external  rectus  and  superior  oblique,  with  a  dilated 
pupil,  a  tongue  deviating  to  the  paralyzed  side,  some  difficulty  in 
articulation,  the  body-palsy  marked  in  the  arm  and  leg,  and  coex- 
isting with  local  temperature  higher  by  several  degrees,  and  very 
defective  sensation. 

The  facts  that  have  been  thus  far  mentioned  are  such  as  have 
been  on  the  whole  well  attested  by  clinical  experience.  But  since 
the  brilliant  researches  of  Hitzig  and  of  Ferrier  on  the  localiza- 
tion of  cerebral  functions,  renewed  eagerness  has  been  displayed 
in  tracing  special  symptoms  to  lesions  of  particular  portions  of 

*  Brown-Sequard,  Dublin  Quart.  Journ.,  May,  18G5. 


DISEASES    OF    THE    BKAIX    AND    SPINAL    CORD.  89 

the  brain.  Some  fresh  problems  have  already  been  solved,  many 
more  are  in  process  of  solution,  and  the  doctrine  of  cerebral  local- 
ization is  becoming  as  interesting  to  the  physician  as  to  the  physi- 
ologist. Let  us  look  at  some  of  the  additions  to  pathological 
knowledge  which  appear  the  most  certain ;  additions  in  which 
the  names  of  Hughlings  Jackson  and  Charcot  will  be  found 
conspicuously  alongside  of  the  distinguished  observers  already 
mentioned. 

We  shall  first  glance  at  lesions  of  the  motor  zone,  or  rather  of 
the  convolutions  functionally  related  to  the  corpus  striatum.  They 
include  the  basis  of  the  three  frontal  convolutions  bounding;  the 
fissure  of  Rolando,  and  are  supplied  by  branches  of  the  middle 
cerebral  artery.  A  lesion  of  these  cortical  parts  causes  paralysis  of 
voluntary  motion  without  loss  of  sensation.  The  hemiplegia  is 
more  or  less  complete  according  to  the  extent  of  the  motor  area 
involved.  It  is  on  the  opposite  side  to  that  of  the  disease,  and, 
as  for  the  most  part  in  the  hemiplegia  connected  with  central 
cerebral  diseases,  neither  the  nutrition  nor  the  electric  contractility 
of  the  palsied  muscles  is  impaired. 

The  cortical  hemiplegia,  when  sudden,  is  less  frequently  accom- 
panied by  loss  of  consciousness,  is  rarely  complete  from  the  first, 
affecting,  perhaps,  at  the  onset  only  an  arm  or  a  leg,  and  is  soon 
followed  by  rigidity  of  the  palsied  parts.  But,  on  the  other  hand, 
it  is  more  apt  to  be  transitory,  to  show  slighter  differences  in  tem- 
perature between  the  two  sides,  and  to  be  accompanied  by  localized 
pain  in  the  head,  which  may  be  elicited  by  percussion  over  the 
seat  of  lesion.* 

Lesions  confined  to  any  one  of  the  gray  central  ganglia,  where 
the  internal  capsule  is  not  involved,  do  not  afford  any  special 
feature  by  which  they  may  be  recognized  from  common  cerebral 
hemiplegia.  There  is  paralysis  of  motion  only,  which,  as  Charcotf 
tells  us,  is  generally  transitory.  If  the  anterior  two-thirds  of  the 
capsule  are  involved,  the  palsy  is  still  exclusively  of  motion, 
though  it  is  more  or  less  persistent,  and  ultimately  accompanied 
by  muscular  contractions ;  if  the  posterior  third  of  the  capsule  is 
also  involved,  we  have  in  addition  cerebral  hemiansesthesia. 


*  Terrier,  Localization  of  Cerebral  Disease,  1879. 

f  Lectures  on  Localization  in  Diseases  of  the  Brain,  New  York,  1878. 


90  MEDICAL    DIAGNOSIS. 

A  lesion  of  one  optic  tract  will  cause  bilateral  hemiopia ;  a  sim- 
ilar effect  is  produced  by  a  lesion  of  the  corpora  geniculata.  Le- 
sions of  the  occipital  lobes  Ferrier  proves  are  as  a  rule  latent. 
There  may  be  considerable  hebetude,  but  no  other  symptom  of  an 
affection  of  the  brain  exists.  In  lesions,  also,  of  the  prefrontal 
lobes,  that  part  which,  in  its  relation  to  the  skull,  is  roughly 
bounded  by  the  coronal  suture,  there  is  no  disorder  either  of 
mobility  or  of  sensibility.  The  manifestations  are  simply  those 
of  restlessness  and  unsteadiness  of  mind  and  other  psychical  dis- 
turbances. 

In  opposition  to  these  doctrines  of  localization  based  on  recent 
research  stand  the  statements  of  the  great  physiologist  Brown- 
Sequard,*  that  the  seat  of  the  lesion  and  that  of  the  apparent  mani- 
festations of  the  disease  are  not  the  same ;  and  that  there  is  a  kind 
of  inhibitory  influence  exerted  on,  or  reflected  irritation  to,  the  va- 
rious parts  of  the  brain.  Nay,  the  cross-action  of  the  hemispheres 
even  is  disputed,  the  disease  occurring  often  on  the  same  side  of 
the  brain.  That  a  certain  number  of  cases  happen  which  prove 
exceptions  to  the  general  law  cannot  be  doubted,  and  in  recent 
instances  of  disease  the  inhibitory  action  on  different  centres  may 
well  confuse  our  ideas  of  localization.  But  they  are  only  excep- 
tions, and  comparatively  too  infrequent  to  impair  the  value  of  the 
general  laws ;  nor  is  it  too  much  to  believe  that  the  cause  of  the 
exception  and  its  diagnostic  meaning  will  be  made  clear  by  the 
advance  of  science. 

The  nature  of  the  paralyzing  lesion,  the  pathological  diagnosis, 
can  be  arrived  at  only  by  a  careful  scrutiny  of  all  the  facts  of  the 
case.  A  sudden  paralysis  occurring  simultaneously  with  coma 
almost  always  has  its  origin  in  an  apoplectic  effusion ;  a  sudden 
paralysis  without  coma  is  generally  due  to  a  rapid  giving  way  of 
a  softened  brain.  A  gradual  development  of  palsy  indicates  some 
chronic  cerebral  disorder,  such  as  softening,  or  a  tumor,  or  any 
affection  compressing  the  nervous  substance.  We  may  also  gain 
much  knowledge  by  carefully  exploring  the  organs  of  circulation 
and  the  kidneys.  Thus,  a  paralysis  found  to  be  conjoined  to  a 
cardiac  malady  or  to  a  diseased  state  of  the  arteries  is,  in  all  like- 


*  In  many  publications  in  the  London  Lancet  and  elsewhere;  and  summed 
up  in  the  Archives  de  Physiologie,  1877. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  91 

lihood,  owing  to  softening,  to  an  apoplectic  effusion  into  the  brain, 
or  to  a  cloo-p-ino;  of  one  of  the  cerebral  arteries  with  a  mass  of 
fibrin.  "When  the  kidneys  are  seriously  disordered,  it  is  generally 
not  unreasonable  to  suppose  that  the  hemiplegia  has  been  caused  by 
some  chronic  disease  of  the  brain,  the  result  of  the  altered  nutri- 
tion produced  by  the  ill-purified  blood. 

A  further  clue  to  the  character  of  the  cerebral  lesion  is  obtained 
by  examining  the  palsied  muscles.  Todd,*  who  clearly  and  for- 
cibly directed  attention  to  this  subject,  declares  that  when  the 
paralyzed  limbs  exhibit  a  rigid  state  from  the  moment  of,  or  soon 
after,  the  attack,  we  may  assume  the  lesion  to  be  of  an  irritative 
nature,  such  as  an  inflammation,  or  a  compression  of  healthy 
brain-tissue  by  an  apoplectic  clot  or  by  an  accumulation  of  puri- 
form  fluid  in  the  subarachnoid  spaces.  When  the  muscular  con- 
traction does  not  take  place  until  late  in  the  complaint,  and 
becomes  associated  with  wasting  of  the  muscles,  it  may  be  pre- 
sumed to  be  caused  by  irritation  from  an  attempt  at  cicatrization. 
The  doctrine  of  the  day  connects  this  late  rigidity  with  a  descend- 
ing sclerosis  of  the  motor  tracts,  though  some  regard  it  as  due  to 
reflex  irritation.  When  the  muscles  are  flaccid  and  relaxed,  and 
there  is,  for  instance,  no  resistance  in  the  flexing  of  the  forearm 
upon  the  arm,  or  of  the  leg  upon  the  thigh,  Todd  teaches  the  lesion 
to  be  of  a  depressing  kind,  such  as  white  softening  of  the  brain, 
with  or  without  rupture  of  the  blood-vessels. 

When  hemiplegia  has  been  of  long  standing,  we  may  enumer- 
ate among  its  symptoms  that  form  of  muscular  rigidity  already 
alluded  to  as  following  a  flaccid  condition  of  muscle,  late  rigidity, 
and  which  may  be  associated  with  atrophy  of  the  muscles  and. 
other  nutritive  changes  that  bespeak  a  secondary  degeneration, 
spreading  into  the  opposite  lateral  column  of  the  spinal  cord; 
also  tremors,  associated  not  unusually,  as  Charcot  tells  us,  with 
diminution  of  sensibility  on  the  palsied  side;  attacks  of  true 
spasms,  happening  particularly  in  the  arms ;  and  choreic  move- 
ments, a  condition  to  which,  under  the  name  of  "post-paralytic 
chorea,"  Dr.  Mitchellf  especially  has  called  attention. 

Hemiplegia  may  he  feigned. %     But  the  results  of  electricity, 

*  Clinical  Lectures  on  the  Nervous  System. 

f  American  Journal  of  the  Medical  Sciences,  Oct.  1874. 

%  For  an  instructive  case,  see  London  Lancet,  April,  1874. 


92  MEDICAL    DIAGNOSIS. 

especially  where  altered  sensibility  as  well  as  defective  motion 
is  simulated,  and  the  test  proposed  by  Hughlings  Jackson,  that 
the  arms  do  not,  as  in  real  hemiplegia,  fall  forward  when  the 
patient  stoops,  but  are  retained  at  the  side,  will  usually  detect 
the  fraud. 

MONOPLEGIA. 

When  we  have  limited  lesions  we  have  limited  palsies,  and  the 
recent  researches  alluded  to  are  teaching  us  more  and  more  accu- 
rately to  recognize  the  centres  affected  in  these  palsies  of  special 
parts,  or  of  one  limb,  or  of  a  group  of  movements.  Of  course, 
in  making  a  diagnosis  of  the  paralysis  being  due  to  disturbance 
of  a  special  nerve-centre,  we  must  be  careful  to  exclude,  as  the 
cause  of  the  local  palsy,  peripheral  affections,  and  those  in  the 
course  of  the  nerve  supplying  the  stricken  part,  and  also  make  it 
clear  that  the  lesion  is  not  spinal  of  very  circumscribed  kind. 
Let  us  now  take  up  some  of  the  limited  palsies  dependent  on 
cerebral  lesion. 

One  arm  only  may  be  paralyzed. — Here  we  find  the  lesion  in 
the  ascending  parietal  and  upper  part  of  the  ascending  frontal 
convolution  on  the  side  opposite  to  the  palsy.  If  the  lesion  be 
double,  as  in  a  case  referred  to  by  Bourdon,*  both  arms  are  help- 
less. But,  whether  single  or  double,  with  the  damaged  motion 
there  are  unimpaired  sensation  and  electro-motor  contractility. 

One  arm  and  the  same  side  of  the  face  are  paralyzed. — In  this 
"brachio-facial  monoplegia"  the  lesion  is  toward  the  middle  or 
lower  third  of  the  ascending  convolutions  in  the  facial  and  manual 
centres.  It  is  a  pure  motor  palsy,  associated,  however,  usually 
with  aphasia  when  the  disease  is  left-sided.  Palsy,  of  cerebral 
origin,  limited  to  one  side  of  the  face,  without  the  arm  being  also 
implicated,  is  rare;  the  cortical  disease  is  in  the  centre  for  the 
facial  region.  The  affection  is  usually  left-sided,  and  is  also  apt 
to  become  complicated  with  aphasia.  The  lower  part  of  the  face 
bears  the  brunt  of  the  palsy;  unlike  Bell's  palsy,  the  orbicularis 
and  the  upper  part  of  the  face  are  but  little,  if  at  all,  disturbed  ;f 
further,  there  is  no  disease  of  the  temporal  bone  to  explain  the 
localized  palsy  by  an  injury  to  the  facial  nerve. 

*Bull.  Soc.  Anat.,  1874. 

f  This  was  strikingly  illustrated  in  a  case  reported  by  Dr.  Guiteras,  Phila. 
Med.  Times,  Nov.  1878. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  93 

The  leg  only  may  be  paralyzed. — This  is  a  very  rare  form  of 
paralysis,  and  presupposes  a  lesion  limited  to  the  motor  centre 
for  the  leg;  but  the  leg-centres  are  not  as  yet  clearly  defined.  In 
some  of  the  cases  of  "  crural  monoplegia"  on  record,  the  ascend- 
ing parietal  and  postero-parietal  convolutions  have  been  found 
diseased.  Sensation  is  not  affected ;  the  arm  is  apt  to  become 
gradually  involved  in  the  palsy. 

There  are  many  other  kinds  of  limited  palsies  of  cerebral  ori- 
gin, such  as  of  the  tongue,  glossophgia,  of  the  eye  muscles,  oculo- 
motov  monoplegia,  to  which  -I  can  only  refer,  since  our  knowledge 
is  not  definite  enough  to  lay  down  conclusions  for  bedside  diag- 
nosis.* I  must,  however,  add  that  in  all  these  limited  palsies 
traceable  to  disease  of  the  brain,  we  are  apt  to  have  such  symp- 
toms as  are  common  in  brain  affection, — headache,  giddiness,  and 
the  like.    These  aid  us  in  understanding  the  nature  of  the  disorder. 

Perhaps,  too,  we  shall  receive  help  from  a  means  of  diagnosis 
recently  inaugurated  by  Broca, — cerebral  thermometry  ;  and  a  higher 
local  temperature  will  point  to  the  region  affected.  But  the  ob- 
servations are  not  as  yet  definite  enough  to  warrant  their  adoption, 
and  what  makes  them  very  difficult  of  application  is,  that  the  dif- 
ference in  the  disease  itself  materially  modifies  the  temperature 
of  the  head.  Thus,  in  embolismf  we  have  a  lower  temperature 
over  the  part  which  ought  to  be  supplied  by  the  occluded  vessel; 
in  inflammation  and  tumor  the  temperature  is  higher.  Again,  as 
we  know  particularly  by  the  elaborate  researches  of  Lombard, 
emotional  activity,  as  well  as  or  even  more  than  intellectual  work, 
causes  a  rise  of  temperature,  the  rise  sometimes  exceeding  0.18° 
Fahr.  (0.1°  Cent).  Thus  the  patient  should  be  examined  when 
free  from  excitement  and  at  rest.     Various  portions  of  the  head 

*  The  works  of  Ferrier  and  Charcot  already  referred  to  ;  Hitzig,  in  "Kli- 
nische  Vortrage  ;"  many  papers  in  the  Archives  de  Physiologie,  in  the  West 
Biding  Eeports,  and  in  "Brain;"  Landouzy,  Blepharotoptose  Cerebrale,  in 
Arch.  Gen.  de  Med.,  Aug.  1877;  paper  on  Glossoplegia,  London  Lancet,  Feb. 
1878 ;  Brown-Sequard,  Ptosis  in  Brain  Disease,  ib. ,  Nov.  1878 ;  Hughlings  Jack- 
son, Clinical  and  Physiological  Besearches  on  the  Nervous  System ;  Pitres, 
Lesions  du  Centre  Ovale ;  Mills,  Cerebral  Localization,  in  American  Jour- 
nal of  the  Medical  Sciences,  July,  1879  ;  Nothnagel,  Topische  Diagnostik  der 
Gehirnkrankbeiten,  Berlin,  1879 — give  us  most  of  the  recent  investigations 
that  are  elucidating  the  subject. 

j  Broca,  Bulletin  de  l'Academie  de  Medecine,  Dec.  1879. 


94  MEDICAL    DIAGNOSIS. 

must  be  selected  as  points  for  the  application  of  the  surface  ther- 
mometer, and  the  corresponding  regions  compared.  The  chief 
regions  are,  on  each  side,  the  frontal ;  the  parietal ;  the  occipital ; 
the  vertical ;  the  side  of  the  head,  in  a  line  below  the  vertex,  and 
above  the  frontal,  parietal,  and  occipital  stations ;  and  the  upper 
section  of  the  entire  head,  on  the  curve  front  and  back  above  this 
line.  For  comparison  we  must  remember  that  the  frontal  region 
in  health  on  the  left  side,  which  always  registers  more,  gives, 
Broca  tells  us,  95.7°  Fahr.  (35.43°  Cent.);  the  parietal,  91.49°; 
Gray  records,  in  accordance  with  Broca,  the  left  occipital  region  as 
92.06°.  The  fact  has  already  been  alluded  to  that  Maragliano  and 
Seppili,  making  their  observations  in  summer,  give  the  mean  nor- 
mal temperature  as  higher  by  nearly  two  degrees  Fahr.  It  is  so 
in  the  frontal  regions,  and  in  the  occipital  region  the  difference  is 
much  greater.  These  authors  tell  us  that  in  the  insane,  the  tem- 
perature varies  much  according  to  the  form  of  insanity.  The 
highest  temperature  is  found  on  the  left  half  of  the  head  and  not 
materially  different  on  the  left  frontal  region,  in  furious  mania, 
36.9°  Cent.  (98.4°  Fahr.) ;  in  progressive  paralysis,  36.6°  (97.9° 
Fahr.);  in  imbecility,  idiocy,  and  simple  mania,  36.3°  (97.3° 
Fahr.);  in  simple  dementia,  36°  (96.8°  Fahr.).  In  locating  brain 
tumors  several  observers  have  made  use  of  the  thermometer.  Gray* 
cites  a  case,  and  Millsf  has  published  several  instances. 

PAEAPLEGIA. 

This  differs  from  hemiplegia  in  the  palsy  occurring  on  both 
sides,  yet  being,  in  the  vast  majority  of  instances,  limited  to  the 
lower  extremities.  It  almost  never  depends  on  disease  of  the 
brain,  its  most  frequent  cause  being  a  lesion  of  the  spinal  cord. 
In  truth,  if  we  call  hemiplegia  paralysis  from  brain  disease,  we 
may  call  paraplegia  paralysis  from  spinal  disease.  There  are, 
however,  cases  in  which  it  exists  independently  of  any  recog- 
nizable structural  change,  and  in  which  it  results  from  poisons, 
from  fatigue,  from  excesses. 

The  disorder  generally  conies  on  slowly.  At  first  the  patient 
only  loses  the  steadiness  of  his  gait;  gradually  he  is  deprived  of 

*  New  York  Medical  Journal,  Aug.  1878,  and  Chicago  Journal  of  Mental 
and  Nervous  Diseases,  Jan.  1879. 

f  Phila.  Med.  Times,  Jan.  1879,  and  New  York  Med.  Record,  Aug.  1879. 


DISEASES    OF    THE    BEAIX    AND    SPINAL    CORD.  95 

all  power  of  motion,  but  the  intellect  and  the  nerves  of  special 
sense  remain  unaffected.  If  the  lesion  be  in  the  lumbar  part  of 
the  cord,  the  paralysis  is  confined  to  the  lower  extremities  and  to 
the  pelvic  muscles ;  if  the  dorsal  portion  be  attacked,  we  find,  in 
addition,  signs  of  paralysis  of  the  abdominal  walls  and  of  the 
sphincters,  tympanites,  and  somewhat  impeded  breathing.  In 
diseases  of  the  upper  section  of  the  cord  there  is  coexisting  palsy 
of  the  upper  extremities,  with  dilated,  sluggish  pupils,  and  diffi- 
culty in  deglutition  and  in  respiration.  In  the  muscles  supplied 
by  the  nerves  which  originate  in  healthy  marrow,  involuntary 
retractions  or  reflex  phenomena  may  be  induced,  and  the  striking 
effects  of  strychnia,  when  given  in  doses  sufficient  to  produce  its 
peculiar  muscular  spasms,  are  manifested.  To  the  effects  of  elec- 
tricity we  have  already  alluded.  The  palsied  muscles,  in  the 
great  majority  of  the  affections  occasioning  the  paraplegia,  do  not 
respond  to  the  electrical  stimulus ;  at  least  they  do  not  after  their 
nutrition  has  become  impaired. 

Paraplegia  is  generally  more  marked  on  one  side  than  on  the 
other,  and  the  paralysis  of  motion  is  apt  to  be  associated  with 
complete  and  permanent  anaesthesia.  When,  as  sometimes  hap- 
pens, the  mischief  is  limited  to  a  lateral  segment  of  any  part  of 
the  cord,  there  is  paralysis  of  motion  on  the  same  side  of  the 
body,  and  of  sensation  on  the  other.* 

Preceding,  or  even  attending,  many  cases  of  paraplegia,  is  a 
symptom  which  belongs  exclusively  to  affections  of  the  cord :  a 
spasm  of  the  flexor  muscles  of  the  lower  limbs,  so  powerful  that 
the  anterior  parts  of  the  thighs  come  almost  in  contact  with  the 
abdomen,  while  the  heels  are  drawn  up  so  as  to  touch  the  back  of 
the  thighs. f 

Let  us  now  take  a  cursory  view  of  the  different  forms  of  spinal 
paraplegia. 

Sudden  paraplegia. — Sometimes  the  paralysis  occurs  suddenly, 
and  in  consequence  of  an  injury  to  the  spine,  of  a  displacement 
subsequent  to  a  disease  of  the  bones,  of  blood  extravasated  into 
the  canal,  of  poisons,  as  the  lathyrus  sativus,|  or  of  bulbar  or 

*  Brown-Sequard's  Lectures  on  the  Nervous  Centres, 
flbid.,  p.  114. 

%  Irving,  Indian  Annals,  No.  12,  referred  to  in  Brit,  and  For.  Med.-Chir. 
Eev.,  Oct.  1860. 


96  MEDICAL    DIAGNOSIS. 

spinal  disorder  from  sudden  displacement  of  the  cerebro-spinal 
fluid  following  blows  on  the  head.*  When  either  of  the  former 
two  causes  has  led  to  the  sudden  palsy,  the  diagnosis  is  materially 
aided  by  the  history  of  the  case,  and  by  a  close  examination  of 
the  vertebral  column.  But  if  there  be  no  history  of  an  injury, 
if  no  signs  of  a  disease  of  the  bones  or  of  the  intervertebral  car- 
tilages can  be  detected,  we  may  suspect  a  spinal  hemorrhage  to 
have  produced  the  sudden  and  complete  paraplegia;  and  this  sus- 
picion becomes  much  strengthened  if  violent  pain  in  the  back 
exist  or  have  preceded  the  complete  palsy,  if  the  patient  be  unable 
to  retain  his  urine  or  fseces,  and  if  the  affected  limbs  be  relaxed 
and  largely  deprived  of  sensation.  These  are  the  symptoms  of 
apoplexy  of  the  cord.  Where  the  hemorrhage  is  meningeal,  there 
is  more  persistent  pain,  with  spasms  of  the  legs,  slight  disturb- 
ance qf  sensibility,  and  far  less  complete  paralysis. 

But,  besides  these  causes,  others  lead  rapidly  to  paraplegia. 
Softening  of  the  cord  may  have  progressed  latently  until  the  de- 
generation destroys  the  continuity  of  the  conducting  tubules,  when 
palsy  at  once  takes  place.  Then  there  are  cases  following  sexual 
excesses,  cases  for  which  neither  during  life  nor  after  death  can 
an  organic  cause  be  assigned,f  and  which  must  therefore  be  viewed 
as  due  to  enfeeblement  of  functional  power.  Similar  cases  of 
spinal  paralysis,  more  or  less  complete,  may  occur  after  fatigue 
and  violent  exercise,  and  some  would  even  seem  to  have  been  in- 
duced by  exposure  to  cold  and  wet,  likewise  without  demonstrable 
organic  change.  In  all  instances  of  spinal  palsy  due  to  impaired 
nerve-power — or  spinal  paresis,  as  Handfield  Jones*  terms  this 
affection — the  disorder  is  much  more  apt  to  come  on  quickly 
than  gradually,  and  a  tonic  treatment  is  likely  to  be  followed  by 
decidedly  good  effects. 

Yet  another  variety  of  piaraplegia  which  may  happen  rapidly 
is  that  form  which  has  been  described  as  acute  ascending  paralysis, 
and  to  which  evidently  many  of  the  cases  of  creeping  palsy  which 
have  been  reported  belong.  It  may  come  on  after  fatigue  and 
exposure  in  persons  in  perfect  health,  and  usually  there  is  little 

*  Duret,  Traumatismes  Cerebraux,  Paris,  1878. 

f  For  instance,  Case  XVIII.  in  Gull"s  admirable  series  of  Cases  of  Para- 
plegia, in  vol.  iv.  Guy's  Hosp.  Hep.,  3d  Series. 
\  Functional  Nervous  Disorders. 


DISEASES    OF    THE    BRAIX    AND    SPINAL    COED.  97 

fever.  Numbness  and  slight  pain  in  the  lower  extremities  are 
soon  followed  by  loss  of  muscular  power,  which,  in  turn,  goes 
on  rapidly,  generally  in  a  few  days,  to  complete  paraplegia.  The 
legs  are  relaxed  and  immovable,  the  muscles  of  the  trunk  are  next 
affected,  then  the  upper  extremities  become  implicated,  and  sen- 
sation, which  at  first  was  normal,  is  somewhat  enfeebled.  The 
patient  is  restless,  sleepless,  but  his  intelligence  is  unimpaired,  and 
we  find  no  bedsores  and  no  palsy  of  the  bladder  or  rectum.  The 
respiration  and  circulation  are  in  the  progress  of  the  disease  apt 
to  become  embarrassed,  and  sudden  death  ensues  within  a  month 
from  the  time  of  the  seizure.*  But  all  cases  do  not  run  so  rapid 
a  course ;  and,  in  truth,  we  meet  with  instances  in  which  the  dis- 
order is  rather  chronic  than  acute,  or,  indeed,  is  arrested.  The 
muscles  in  any  case  atrophy,  although  not  to  a  very  marked  ex- 
tent; and  in  those  involved,  the  electro-muscular  contractility  is 
diminished,  so,  at  least,  it  is  stated  in  some  of  the  observations  on 
record,  while  in  the  most  recent  researches,  particularly  those  of 
Westphal,  the  unimpaired  electrical  excitability  is  regarded  as  a 
valuable  diagnostic  test.  Equally  conflicting  are  the  statements 
about  reflex  excitability.  It  is  generally  but  very  slowly  changed, 
although  Jaccoudf  tells  us  that  in  the  cases  he  observed,  there 
was  anaesthesia  localized  over  the  affected  parts,  and  that  the  reflex 
movements  were  abolished.  The  disease  which  most  resembles  it 
is  acute  progressive  neuritis,  where  nerve  after  nerve  becomes  in- 
flamed. But  here  sensation  is  rapidly  lost,  so  is  the  electrical  ex- 
citability.J     Where  the  primary  lesion  is,  has  not  been  decided. 

Gradual  paraplegia. — This  occurs  in  congestion,  in  acute  and 
chronic  inflammation  of  the  meninges,  in  myelitis,  in  softening, 
in  atrophy,  in  sclerosis,  in  compression  of  the  cord,  and  from 
reflex  irritation.  It  is  difficult  to  determine  the  features  by 
which  these  different  morbid  conditions  may  be  distinguished 
from  one  another;  indeed,  a  distinction  is  not  always  possible. 
These  are  some  of  the  marks  of  discrimination  : 

In  congestion  of  the  cord  there  is  dull  pain,  generally  confined 
to  the  lumbar  and   sacral  regions;   the  palsy  progresses  slowly 

*  As  in  the  case  reported  by  Hayem,  Travaux  de  la  Societe  iledieale  d'Ob- 
servation,  tome  ii.,  1867. 
f  Clinique  Medicale. 
\  See  the  case  of  Eichhorst,  Yirchow's  Archiv,  lxix.,  1877. 


98  MEDICAL    DIAGNOSIS. 

from  below  upward,  is  preceded  by  numbness,  is  incomplete,  and 
rarely  combined  with  paralysis  of  the  sphincters.  Moreover,  the 
difficulty  in  walking  is  much  greater  on  arising  after  a  night's 
rest,  or  indeed  whenever  the  patient  has  been  for  any  length  of 
time  in  the  recumbent  posture.  We  may  often,  too,  trace  the 
congestion  to  some  disturbance  of  the  circulation,  especially  of 
the  abdominal  circulation  ;  or  to  alterations  in  the  composition  of 
the  blood,  as  in  rheumatism,  smallpox,  or  typhus;  or  we  find  it 
as  a  result  of  exposure  to  cold  and  wet,  or  of  standing  for  a  long 
time,  or  as  a  sequel  of  the  malarial  fevers. 

Similar  in  its  symptoms  to  spinal  congestion,  though  very  dis- 
similar in  its  causation,  is  sjnnal  anaemia.  A  disease  usually  of 
young  females,  and  forming  part  of  a  general  anaemic  condition,  or 
following  exhausting  discharges,  it  becomes  strangely  mixed  with 
the  symptoms  of  hysterical  spine,  or  "  spinal  irritation,"  which, 
indeed,  is  described  as  anaemia  of  the  cord  by  Hammond.* 

The  traits  distinguishing  spinal  anaemia  from  congestion  are, 
that  in  the  former  we  have  much  more  marked  head,  chest,  and 
abdominal  distress,  such  as  vertigo,  palpitation,  neuralgic  chest 
pains,  nausea,  and  other  dyspeptic  symptoms.  The  inactive  or 
slightly  palsied  limbs — though  affections  of  motility  are  far  from 
constant — are  not  infrequently  the  seat  of  spasms,  are  sensitive  to 
the  touch,  act  better  after  having  been  in  the  recumbent  posture ; 
pressure  on  the  spinous  processes  of  the  vertebrae  shows  also 
marked  tenderness.  In  doubtful  cases,  Hammond  proposes  as  a 
test  a  hypodermic  injection  of  the  thirtieth  of  a  grain  of  strychnia, 
which  is  beneficial  in  spinal  anaemia,  but  temporarily  aggravates 
the  symptoms  of  congestion. 

In  inflammation  of  the  meninges  we  encounter  severe  pain  in 
the  back,  little  influenced  by  pressure  upon  the  spine,  yet  aggra- 
vated by  movement,  even  by  the  acts  of  defecation  and  of  urina- 
tion ;  sometimes  a  sensation  as  if  a  cord  had  been  drawn  around 
the  belly;  pains  in  the  limbs  similar  to  those  of  rheumatism; 
cutaneous  hyperesthesia;  muscular  twitchings  and  contractions, 
more  or  less  permanent  and  painful ;  and  very  commonly  dis- 
tressing spasms  in  the  muscles  of  the  back;  rigidity  of  the  spinal 
column;  bedsores;  dyspnoea;  retention  of  urine;  yet  only  incom- 

*  Diseases  of  the  Nervous  System. 


DISEASES    OF    THE    BRAIN    AND    SPIXAL    CORD.  99 

plete  paralysis,  or,  indeed,  none  at  all.  When  marked  paraplegia 
follows  the  symptoms  mentioned,  we  may  suspect  myelitis  or  that 
an  effusion  has  taken  place  which  compresses  the  spinal  cord. 
Cases  of  spinal  meningitis  occur  from  falls  and  shocks,  and  from 
exposure  to  cold ;  they  are  not  unusual  among  soldiers  who  have 
slept  on  damp  ground.  As  regards  the  special  membranes  in- 
volved, there  is  no  certainty  in  diagnosis.  The  symptoms  alluded 
to  are  seen  in  their  fullest  development  in  inflammation  of  the 
spinal  pia  mater  and  arachnoid.  In  inflammation  of  the  inner 
surface  of  the  dura  mater,  "  pachymeningitis  interna,"  which  par- 
ticularly happens  in  the  cervical  region,  the  symptoms  are  chiefly 
there  referred ;  and  stiffness  of  the  neck,  paralysis  in  the  upper 
extremities,  especially  in  the  parts  supplied  by  the  median  and 
ulnar  nerves,  claw-like  hands,  contractions,  spots  of  anaesthesia, 
and  herpetic  eruptions  are  common.  At  a  later  period  the  lower 
extremities  may  become  paralyzed. 

Myelitis  presents  many  of  the  same  symptoms  as  spinal  menin- 
gitis. But  they  generally  come  on  by  slow  degrees,  and  the  para- 
plegia becomes  complete.  Contractions  of  the  muscles  are,  in 
inflammation  of  the  cord,  uncommon,  and  not  permanent,  unless 
late  in  the  disease;  the  muscles  are  usually  limber;  there  is  com- 
paratively little  pain,  none  on  pressure  at  any  part  of  the  spine,  or 
on  motion,  and  anaesthesia  sooner  or  later  shows  itself.  Further, 
we  generally,  though  not  constantly,  find  the  urine  alkaline,  and, 
as  a  rule,  a  want  of  control  over  the  bladder  and  rectum  exists, 
bedsores  form  readily,  and  the  temperature  of  the  palsied  is  lower 
than  that  of  the  healthy  parts. 

In  acute  cases  there  are,  as  in  acute  spinal  meningitis,  with 
which,  indeed,  myelitis  may  be  complicated,  heat  of  skin  and  a 
frequent  pulse'.  In  many  instances  we  notice  erection  of  the 
penis.  Reflex  movements  in  the  palsied  limbs,  at  first  still  easily 
excited,  and  excited,  too,  by  irritation  elsewhere  applied,  are 
gradually  abolished  as  the  process  of  inflammation  and  softening 
extends  to  the  gray  matter  of  the  cord.  An  altered. sensibility  to 
heat  and  cold,  when,  for  instance,  a  sponge  soaked  in  warm  water 
or  a  piece  of  ice  is  applied  to  the  spine  over  the  inflamed  spot,  has 
been  spoken  of  as  a  diagnostic  test.  In  either  case  the  sensation, 
when  the  diseased  part  is  reached,  changes  to  a  burning  sensation. 
This  symptom   is,   however,  far  from  constant,  and  cannot  be 


100  MEDICAL    DIAGNOSIS. 

accepted  as  conclusive.  The  paraplegia,  even  in  acute  cases,  is 
not  suddenly  developed.  Yet  we  meet  with  marked  exceptions. 
There  are  instances  in  which  it  comes  on  as  rapidly  as  in  spinal 
hemorrhage,*  and  without  attending  loss  of  sensibility;  or  a 
paralysis  of  the  bladder  is  the  first  symptom,  and  paralysis  of 
motion  and  of  sensation  quickly  follows.f 

Myelitis  may  be  the  result  of  cold  and  exposure,  of  syphilis,  of 
peripheral  irritation,  of  pressure,  as  from  disease  of  the  vertebra, 
or  of  tumors,  connected  with  the  bones  or  membranes,  encroaching 
on  the  cord  and  setting  up  disease  there.  Such  instances  have 
been  noted  in  the  cervical  as  well  as  in  the  other  portions  of  the 
spine.  Paralysis  of  the  arms,  with  dilated  or  contracted  pupil 
and  very  slow  pulse,  is  among  the  chief  symptoms  of  the  "  cer- 
vical paraplegia."^  Pain  in  the  limbs,  hyperesthesia,  muscular 
contraction,  spasms,  and  great  reflex  irritability  are  among  the 
earlier  symptoms  of  this  as  of  all  the  other  forms  of  myelitis  from 
pressure ;  but  as  the  case  progresses  the  reflex  irritability  is  lost, 
and  with  it  disappear  the  electro-muscular  contractility  and  sen- 
sibility.    Yet  recovery,  almost  complete,  is  possible.§ 

In  looking  at  the  symptoms  which  mark  the  extent  and  exact 
site  of  the  inflammation,  we  find  in  the  ordinary  form,  where  the 
disease  affects  a  considerable  portion  of  the  thickness  of  the  cord, 
— the  transverse  myelitis, — with  the  ordinary  symptoms  of  com- 
plete paraplegia  and  anaesthesia,  that  the  reflex  excitability  is  pre- 
served or  even  increased,  and  that  the  muscles  respond  to  the 
electric  current.  This  is  not  the  case  in  central  myelitis,  which, 
moreover,  usually  runs  a  rapid  course,  and  in  which  muscular 
atrophy  shows  itself.  In  disseminated  myelitis  there  are  lulls  and 
exacerbations,  the  paralysis  is  not  so  constant  or  complete,  although 
it  may  be  in  all  four  limbs,  spastic  symptoms  are  not  uncommon, 
and  the  disease  develops  itself  after  acute  maladies,  as  after  small- 
pox. Hemorrhagic  myelitis  is  usually  central ;  the  paraplegia 
comes  on  in  less  than  an  hour,  and  we  can  only  distinguish  it  from 
pure  hemorrhage  into  the  cord  if  fever  and  other  symptoms  of  an 
acute  myelitis  previously  existed. 

Softening  of  the  cord  cannot  with  any  certainty  be  distinguished 

*  Hayem,  Archives  de  Physiologie,  Sept.  1874. 

f  Erb,  in  Ziemssen's  Cyclopaedia,  vol.  xiii. 

I  Bosenthal,  op.  cit.  \  Buzzard,  "Brain,"  April,  1880. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  101 

from  myelitis ;  the  inflammation  is,  in  truth,  the  usual  cause  of 
the  softening.  Nor  can  the  paraplegia  consequent  upon  atrophy 
of  the  cord  be  clearly  separated.  Indeed,  of  atrophy,  except  when 
in  connection  with  sclerosis,  we  have  no  trustworthy  knowledge. 

Now,  this  atrophy  of  the  nerve-substance,  which  goes  hand-in- 
hand  with  the  increase  of  the  connective  tissue,  may  be  found  in 
any  part  of  the  cord,  may  show  itself  as  a  uniform  alteration,  or 
affect  part  of  the  cord  here,  part  there,  giving  rise,  therefore,  to 
disseminated  patches  of  disease.  Again,  we  may  have  the  same 
alteration  in  portions  of  the  brain,  or  the  lesion  may  be  limited 
to  any  section  of  the  cord ;  for  instance,  it  may  affect  merely  the 
posterior  columns.  The  sclerosis  where  brain  and  cord  both  suffer, 
we  shall  presently  discuss  with  the  forms  of  tremor;  posterior 
sclerosis  of  the  cord  gives  us  the  symptoms  of  locomotor  ataxia. 
But  with  reference  to  sclerosis  of  the  antero-lateral  columns  some 
words  here  are  necessary.  It  usually  originates  without  known 
cause,  though  we  may  find  it  following  jars  and  blows  to  the  spine, 
or  well-marked  attacks  of  inflammation  of  the  cord.  It  may  be 
hereditary,  and  is  pre-eminently  a  disease  of  middle  age,  lasting 
for  years,  showing  at  times  striking  ameliorations,  but,  except 
when  of  syphilitic  origin,  never  resulting  in  a  cure.  The  para- 
plegia which  it  induces  begins  rather  suddenly,  but  is  at  first  very 
incomplete ;  certain  movements  alone  are  impossible ;  the  feet  in 
walking  are  not  raised  high  enough  from  the  ground,  and  the 
patient  is  apt  to  stumble.  Reflex  movements  are  increased,  they 
are  certainly  not  abolished  ;  sensation  is  good,  and  so  is  at  first  the 
electro-muscular  contractility.  In  advanced  cases,  this  becomes 
much  impaired,  and  absolute  loss  of  power  of  voluntary  motion, 
derangement  of  bladder  and  rectum,  defective  eyesight,  without, 
however,  any  brain-symptoms,  muscular  wasting  and  contractions, 
form  a  very  distressing  combination  of  symptoms.  The  tendon 
reflexes  are  increased ;  pain  there  is  none,  unless  from  coexisting 
chronic  meningitis ;  and  anaesthesia,  which,  when  present,  is  most 
apparent  in  the  soles  of  the  feet,  shows  that  the  malady  has  spread 
to  the  posterior  sections. 

Looked  at  from  a  diagnostic  point  of  view,  we  separate  antero- 
lateral sclerosis  from  chronic  myelitis  by  the  slower  beginning  but 
more  rapid  course  of  the  latter,  the  much  more  profound  palsy, 
the  muscular  spasms  happening  early  in  the  malady,  not  late,  as 


102  MEDICAL    DIAGNOSIS. 

they  do,  if  they  happen  at  all,  in  sclerosis,  the  far  less  diminution 
of  electro-muscular  contractility  and  the  comparative  absence  of 
bladder-affection  which  this  shows.  From  congestion  of  the  cord, 
which  also  may  begin  acutely,  antero-lateral  sclerosis  may  be 
diagnosticated  by  the  history  of  the  case,  the  varying  and  incom- 
plete palsy  in  the  former  malady,  its  being  influenced  by  the 
recumbent  posture,  the  pain  in  the  back,  the  sensation  of  numb- 
ness in  the  legs,  and  the  usual  and  early  anaesthesia.  There  are 
puzzling  cases  for  diagnosis  between  some  forms  of  sclerosis  and 
tumors  of  the  brain  ;  but  the  choked  disks,  the  marked  headache, 
the  vertigo,  the  vomiting,  the  palsies  of  the  cerebral  nerves,  help 
us  to  distinguish  the  latter,  while  in  the  cerebro-spinal  variety  of 
sclerosis,  although  we  have  cerebral  symptoms,  we  find  the  charac- 
teristic tremor. 

When  sclerosis  affects  the  lateral  columns,  and  is  combined  with 
degeneration  of  the  great  ganglion  cells  in  the  anterior  horns  of 
gray  matter  of  the  cord,  the  portion  which  we  know  to  have  a  kind 
of  controlling  influence  over  nutrition,  marked  nutritive  changes 
happen  in  the  palsied  part,  such  as  we  find  in  progressive  mus- 
cular atrophy.  But  the  lateral  amyotrophic  sclerosis,  as  Charcot, 
who  first  described  it,  has  termed  it,  is  from  the  onset  an  atrophy 
of  a  whole  muscular  group.  It  is  a  disease  which  lasts  only  a  few 
years,  not  many  as  does  progressive  muscular  atrophy,  affects  as  a 
rule  the  four  limbs  successively,  beginning  in  the  arms,  produces 
strange  deformities  in  the  wasted  and  palsied  limbs,  which  are 
often  agitated  by  fibrillar  movements,  extends  to  the  hypoglossal 
and  to  the  pneumogastric  nerves,  and  thus  determines  death. 

Primary  sclerosis  of  the  lateral  columns  in  which  the  anterior 
horns  are  not  affected  gives  the  group  of  symptoms  described  as 
spasmodic  dorsal  tabes  by  Charcot,  or  spastic  spinal  paralysis  by 
Erb.  It  is  characterized  by  gradually  increasing  loss  of  muscular 
power  in  the  lower  extremities,  proceeding  slowly  from  below  up- 
wards, and  associated  with  reflex  spasms  and  persistent  muscular 
contractions,  with  increased  tendon  reflex,  but  without  impair- 
ment of  sensibility  or  muscular  atrophy,  or  trophic  disturbances, 
or  bedsores,  or  vesical  disorder.  The  gait  is  very  peculiar,  the 
walk  being  on  the  toes,  and  as  the  foot  touches  the  ground  a 
trembling  happens.  There  are  no  cerebral  symptoms  whatever; 
the  electrical  excitability  is  rather  lessened.     In  rare  instances  the 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  103 

disease  begins  in  the  upper  extremities;  it  is  almost  always  of 
very  slow  development.  Occasionally  it  terminates  in  recovery. 
Whether  this  group  of  symptoms,  however,  may  not  be  produced 
by  various  lesions  of  the  cord  is  not  settled.  Seguin  strongly 
holds  this  view.*  To  an  infantile  form  of  degeneration  of  the 
lateral  columns  McLane  Hamilton  has  recently  called  attention. 
Loss  of  power  in  the  lower  extremities,  muscular  contractions 
without  marked  atrophy  or  greatly  impaired  electro-muscular  con- 
tractility, as  happen  in  infantile  paralysis ;  increased  skin  and 
tendon  reflexes,  and  absence  of  sensory  disturbances  or  brain 
symptoms,  are  the  chief  signs  of  the  affection. f 

Tumors  of  the  spinal  cord,  either  growing  from  it  or  its  mem- 
branes, or  originating  in  the  vertebrae  and  compressing  the  nerve- 
structure,  occasion  paraplegia.  But  the  cause  is  beyond  the  reach 
of  positive  diagnosis.  We  suspect  the  affection  if  we  have  ema- 
ciation and  signs  of  a  grave  constitutional  malady  attending  the 
palsy,  if  this  be  more  decided  on  one  side  than  on  the  other,  and 
anaesthesia  be  found  on  the  side  opposite  to  that  in  which  the  palsy 
is  marked  and  which  is  the  seat  of  the  tumor.  Then  severe  pain 
over  the  locality  of  the  disease  occurs  in  cancerous  new  formations, 
— and  most  spinal  tumors  are  cancerous, — and  is  aggravated  in 
paroxysms.  Yet,  unless  we  have  distinct  evidence  of  tumors 
elsewhere,  the  diagnosis  is  never  more  than  an  uncertain  one.  If 
multiple  tumors  exist,  it  may  be  made  positive.  Strong  proofs  of 
syphilitic  infection  point  to  the  spinal  symptoms  being  due  to  a 
syphilitic  growth,  and  signs  of  scrofula,  or  tubercle  in  the-  lungs 
or  in  other  internal  organs,  make  it  likely  that  similar  morbid 
products  are  the  cause  of  the  palsy.  Should  a  gradually  progress- 
ing paralysis  suddenly  show  symptoms  of  acute  myelitis  in  a  per- 
son with  the  constitutional  cachexia  just  mentioned,  we  have  an 
additional  reason  for  supposing  the  affection  to  be  tubercular  and 
to  be  rapidly  extending.^ 

But  what  of  reflex  paraplegia?  How  can  we  isolate  it  from 
the  paraplegia  of  organic  spinal  origin  ?  Not  with  any  certainty, 
unless  we  can  discern  the  source  of  the  irritation,  obtain  a  clear 
history  of  the  case,  and  satisfy  ourselves  of  the  absence  of  the 

*  New  York  Archives  of  Medicine,  Feb.  1879. 

f  Transactions  of  the  American  Medical  Association,  1879. 

X  See  cases  of  Hayem,  Archives  de.Physiologie,  1873. 


104  MEDICAL    DIAGNOSIS. 

special  symptoms  of  an  organic  disease  of  the  spine  or  the  cord. 
Some  distinctive  features  are,  that  the  muscles  do  not  become 
atrophied  ;  that  their  reflex  power  is  comparatively  unimpaired ; 
that  anaesthesia  is  exceptional ;  that  the  palsy  is  seldom  complete ; 
that  some  muscles  are  much  more  affected  than  others ;  that  spasms 
in  the  paralyzed  muscles  are  uncommon ;  that  there  are  very  rarely 
pains  in  the  spine,  produced  either  spontaneously,  or  by  pressure, 
or  by  percussion,  or  by  applying  ice  or  a  hot  moist  sponge ;  and 
that  there  is  a  correspondence  between  changes  in  the  degree  of 
the  paralysis  and  changes  in  the  visceral  disease  or  external  irrita- 
tion which  is  supposed  to  have  produced  the  paraplegia. 

So  much  for  paraplegia.  We  shall  now  examine  some  of  the 
other  clinical  varieties  of  paralysis;  beginning  with  a  group  in 
which  the  palsy  is  limited,  though  it  may  be  general. 

PALSIES   USUALLY  LIMITED,  THOUGH  THEY  MAY  BE  GENERAL. 

Here  we  encounter  hysterical  paralysis.  In  hysterical  paralysis 
there  is  no  structural  affection  of  the  brain,  yet  all  looks  as  if  this 
were  the  case.  This  form  of  paralysis  we  distinguish  from  that  of 
organic  disease,  by  its  occurrence  in  hysterical  persons  ;  its  sudden 
appearance,  and  frequently  its  just  as  sudden  disappearance;  its 
coming  on  generally  under  the  influence  of  some  powerful  emo- 
tion; the  absence  of  any  signs  of  a  serious  lesion  of  the  nervous 
centres,  except  the  paralysis;  its  incomplete  character,  the  patient 
being  sometimes  able  to  move  while  under  strong  excitement;  and 
the  ease  with  which  reflex  movements  are  brought  on  in  the  seem- 
ingly helpless  limb.  Moreover,  we  have  a  valuable  differential 
test  in  electricity.  The  muscles,  except  in  cases  of  long  standing, 
respond  perfectly  to  its  stimulus,  although,  as  we  are  told  by 
Duchenne,  the  electro-muscular  sensibility  is  either  diminished  or 
abolished,  while  in  cerebral  paralysis  it  is  intact. 

Persons  affected  with  hysterical  palsy  are  striking  types  of  what 
may  be  called  a  nervous  constitution,  and,  as  Sir  James  Paget*  in 
his  admirable  lectures  points  out,  show  a  singular  readiness  to  be 
painfully  fatigued  by  slight  exertion.  The  palsy  may  seize  only 
upon  one  limb,  or  part  of  one  limb,  or  upon  special  muscles,  as 
those  of  the  pharynx  and  oesophagus,  the  larynx,  the  intestines, 

*  Nervous  Mimicry  of  Organic  Diseases,  in  Clinical  Lectures  and  Essays, 
London,  1875. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  105 

and  the  diaphragm ;  or  it  may,  although  it  more  rarely  does, 
assume  a  hemiplegic  or  paraplegic  form.  Hysterical  hemiplegia 
presents  a  peculiarity  in  the  gait,  on  which  Todd*  lays  great  stress. 
"In  walking,  when  the  palsy  is  pretty  complete,  the  leg  is  drawn 
along  as  if  lifeless,  sweeping  the  ground."  It  is  not  swung  round, 
describing  the  arc  of  a  circle,  as  it  is  in  ordinary  hemiplegia.  The 
palsy  is  almost  invariably  left-sided.  It  may  be  conjoined  to  very 
decided  anaesthesia,  which  passes  beyond  the  paralyzed  part  to  the 
nearest  portion  of  skin  and  mucous  membrane,  though,  as  a  rule, 
still  limited  to  the  same  side.  Thus  we  find  the  pituitary  mem- 
brane of  one  nostril  rendered  insensible,  if  the  loss  of  feeling 
affect  the  face.  In  hysterical  paraplegia  we  find  the  same  incom- 
pleteness of  the  palsy  and  the  same  electric  tests  already  men- 
tioned, and  we  are  also  very  apt  to  have  the  symptoms  of  spinal 
irritation.  Hysterical  contractions  of  the  muscles  especially  affect 
the  lower  extremity.  These  hysterical  contractures,  as  some,  adopt- 
ing the  French  name,  have  called  them,  generally  come  on  sud- 
denly, appear  to  be  permanent,  and  to  be  associated  with  palsy  of  one 
or  both  legs,  but  disappear  as  suddenly  as  they  showed  themselves. 
Yet  they  may  really  become  permanent  and  combined  with  sclerosis 
of  the  cord. 

Rheumatic  paralysis  resembles  hysterical  paralysis  in  being 
ordinarily  limited.  It  may  affect  any  muscle  or  any  group  of 
muscles  in  the  body ;  sometimes  the  rheumatic  poison  disorders 
the  portio  dura,  and  we  observe,  in  consequence,  facial  palsy ;  or  it 
may  fasten  on  the  radial  nerve,  and  we  have  groups  of  muscles  in 
the  forearm  palsied.  Rheumatic  paralysis  is  recognized  by  the 
history  of  the  case ;  by  the  evidences  of  a  rheumatic  attack ;  by 
the  rapid  development  of  the  palsy ;  by  the  pain  wmich  usually 
attends  it :  and  by  its  being  unaccompanied  by  symptoms  strictly 
referable  to  a  disease  of  the  nerve-centres.  It  may  or  may  not 
be  attended  by  anaesthesia.  The  muscles  themselves,  certainly  in 
those  cases  in  which  they,  rather  than  a  large  nervous  branch,  are 
primarily  and  chiefly  affected,  are  readily  acted  upon  by  electricity, 
unless  their  structure  be  altered ;  and  the  electro-muscular  sensi- 
bility, though  it  may  be  lessened,  is  not  abolished. 

Paralysis  from  lead  poisoning  occurs  primarily,  and  sometimes 

*  Clinical  Lectures  on  Paralysis  and.  other  Affections  of.  the  Nervous  Sys- 
tem, Lecture  XIII. 


1  06  MEDICAL    DIAGNOSIS. 

only,  in  the  extensor  muscles  of  the  arm,  occasioning  the  well- 
known  wrist-drop.  Gradually  other  muscles  become  involved: 
there  is  loss  of  power  in  the  ball  of  the  thumb,  in  the  deltoid, 
and  in  the  triceps;  but  not  in  the  intercostal  muscles,  or  in  those 
of  the  lower  extremities.  The  disturbed  muscles  on  both  sides  of 
the  body  waste,  and  entirely  lose  their  irritability  to  electricity. 
The  patient  is  weak ;  his  movements  are  tremulous ;  he  has  the 
peculiar  blue  line  on  the  gums;  is  obstinately  constipated,  and  is 
subject  to  colic.  Sometimes  the  poison  seizes  upon  the  brain,  and 
epileptic  convulsions  and  other  signs  of  a  serious  cerebral  aifection 
appear,  and  with  the  ophthalmoscope  we  find  marked  optic  neuritis. 
From  the  locality  of  the  palsy,  in  addition  to  the  accompanying 
symptoms  and  the  knowledge  of  the  man's  employment,  the  diag- 
nosis is  usually  arrived  at  with  ease.  Paralysis  produced  by  an 
affection  of  the  radial  nerve  shows  the  greatest  similarity.  But 
here  the  supinator  muscles  as  well  as  the  extensors  are  affected, 
which  is  not  the  case  in  lead  paralysis,  where  the  patient  can  carry 
the  hand  supine. 

Diphtheritic  paralysis  is  a  remarkable  sequel  of  diphtheria.  It 
follows  an  attack  of  that  disease  within  a  fortnight  or  two  months, 
and,  therefore,  after  the  patient  is  apparently  fully  convalescent. 
It  may  be  very  localized,  merely  affecting  the  palate  or  the 
pharynx;  or  very  general,  fastening  upon  both  of  the  lower  extrem- 
ities, and  even  upon  the  upper.  When  extensive,  it  is  always 
ushered  in  by  a  throat-palsy.  It  ensues  gradually, — day  by  day 
the  muscular  power  is  more  and  more  enfeebled.  The  loss  of 
motion  is  often  preceded  by  formication,  and  attended  by  a  certain 
amount  of  anaesthesia.  The  electro-muscular  contractility  and  sen- 
sibility are  diminished,  and  the  continuous  current  shows  mostly 
the  same  results.  The  palsy  mends  as  slowly  as  it  comes  on  ;  yet 
most  cases  fully  recover.  The  brain  itself  shows  no  signs  of  dis- 
ease ;  at  least  there  were  no  symptoms  of  cerebral  mischief  in  the 
cases  which  have  come  under  my  observation. 

Paralysis  from  syphilis  we  find  in  persons  presenting  signs  of 
constitutional  syphilis,  and  in  whom  any  serious  nervous  disturb- 
ance may  be  looked  upon  as  pointing  to  a  local  manifestation  of 
syphilis  in  the  nervous  centres.  Not  unusually  the  syphilitic 
exudation  is  localized  in  the  course  of  one  or  several  nerves,  and 
we  have,  for  instance,  paralysis  of  one  of  the  sixth  pair,  or  paral- 


DISEASES    OF    THE    BKAIN    AND    SPINAL    COED.  107 

ysis  of  the  fifth  with  or  without  paralysis  of  some  other  cerebral 
nerve.  But  as  syphilis  attacking  the  nervous  system  is  chiefly 
characterized  by  a  want  of  uniformity  in  the  lesions  it  produces, 
so  we  observe  very  dissimilar  phenomena  preceding  or  attending 
the  palsies.  Thus,  we  may  or  may  not,  though  in  point  of  fact 
we  usually  do,  find  the  paralysis  associated  with  pain  in  the  head, 
with  optic  neuritis,  with  sleeplessness,  vertigo,  impaired  memory, 
and  sickness  at  the  stomach.  Decided  vertigo  is  prone  to  take 
place  where  the  syphilitic  affection  has  led  to  disease  of  the  ves- 
sels, and  is  apt  to  be  the  forerunner  of  local  softenings  and  of 
hemiplegia.  When  disease  of  the  membranes  has  happened, 
headache  is  generally  severe,  and  convulsions  occur.  The  same 
symptoms  are  encountered  when  there  is  a  growth  in  the  hemi- 
sphere ;  though  here  again  the  form  of  mischief  may  be  compara- 
tively latent,  the  patient  may  have  only  occasionally  convulsions, 
and  the  paralysis  be  slight  or  improving,  yet  a  fatal  coma  may 
follow  a  few  convulsions.  Instances  of  this  have  come  under  my 
observation. 

But,  as  a  rule,  syphilitic  paralysis  does  not  terminate  fatally. 
In  truth,  the  ease  with  which  the  palsy  and  its  attending  phe- 
nomena yield  to  treatment,  if  we  except  marked  instances  of  hard 
nodules,  forms  one  of  the  traits  of  the  malady.  Other  common 
features,  to  speak  in  general  terms  and  taking  into  account  what 
has  been  said  of  the  dissimilar  character  of  the  lesions,  are — that 
it  ordinarily  affects  persons  younger  than  those  in  whom  we  find 
paralysis  dependent  upon  disease  of  the  nervous  centres,  and  espe- 
cially of  the  brain ;  and  that  its  manifestations  are  shifting  and 
capricious.  These  same  traits  characterize  syphilitic  affections  of 
the  nervous  system  in  which  paralysis  is  not  among  the  symptoms. 
Paralysis  of  the  third  nerve  is  a  frequent  result  of  syphilis,*  but 
we  may  have,  as  already  stated,  the  poison  attacking  any  part  of 
the  nervous  system,  and  paraplegia  dependent  upon  disease  of  the 
cord  is  not  very  uncommon.  It  is  among  the  peculiar  traits  in  the 
syphilitic  palsy  that  the  lost  electro-muscular  contractility  returns 
rapidly.f 

The  mischief  to  the  nervous  system  may  not  happen  for  years 
after  the  infection.    It  may  be  the  result  of  an  inherited  taint.    But 

*  Broadbent,  Lancet,  Jan.  1874. 

f  Engel,  Phila.  Med.  Times,  Dec.  1877. 


108  MEDICAL    DIAGNOSIS. 

such  cases  cannot  be  recognized  unless  there  are  other  signs  of 
syphilis  than  the  suspected  nervous  symptoms;  and  chief  among 
these  signs  is  that  valuable  test  of  congenital  syphilis  discovered 
liv  Mr.  Hutchinson, — a  malformation  of  the  two  upper  central 
permanent  incisors,  which  consists  in  their  being  narrower  at  their 
cutting  edges  than  at  their  insertions,  and  often  notched.  The 
same  observer  has  called  attention  to  the  diffused  opacity  of  the 
cornea  and  the  diseased  nails  common  among  the  manifestations 
of  the  inherited  disease.  Paralysis  also  may  occur,  as  in  the  case 
reported  by  Bartlett  j*  but  it  is  very  rare. 

LOCAL    PALSIES. 

The  forms  of  paralysis  which  have  just  been  noticed  are  mainly 
such  as  are  designated  as  partial.  When  the  loss  of  power  is 
very  limited,  the  palsy  is  generally  spoken  of  as  local.  Several 
of  these  local  paralyses  are  of  great  interest ;  the  one,  however, — 
from  its  frequency,  and  from  its  being  often  mistaken  for  a  sign  of 
intra-cranial  disease, — of  particular  importance,  is  facial,  or  Bell's 
palsy.  The  disease  consists  in  an  affection  of  the  portio  dura  of 
the  seventh  pair.  In  consequence  of  the  derangement  of  this 
motor  nerve,  nearly  all  the  muscles  of  the  face  lose  their  faculty 
of  motion,  and,  as  it  is  their  play  which  gives  expression  to  the 
countenance,  the  appearance  of  the  face  is  extraordinary.  The 
eyelids  are  open  and  fixed;  the  features  are  rigidly  composed  on 
one  side  of  the  face,  but  reflect  everv  change  of  feeling  on  the 
other.  In  some  cases  the  velum  palati  is  involved  in  the  paralysis. 
But  sensation  remains  unimpaired  as  long  as  the  fifth  nerve  is 
not  disturbed. 

The  causes  of  the  palsy  are  such  as  influence  the  distressed 
nerve  in  its  course  or  at  its  periphery  :  a  wound  ;  mumps ;  otitis  ; 
exposure  to  cold.  Not  being  due  to  a  cerebral  malady,  it  is  not  a 
sign  of  serious  danger.  It  is  easily  discriminated  from  the  facial 
palsy  of  disease  of  the  brain  by  the  inability  to  close  the  eyelids, 
owing  to  the  paralysis  of  the  orbicularis  palpebrarum ;  by  the 
absence  of  headache,  of  vertigo,  of  mental  confusion,  of  loss  of 
memory ;  by  the  much  more  complete  though  strictly  local  char- 
acter of  the  paralysis;  and,  ordinarily,  by  the  lost  electro- muscular 

*  Clinical  Society's  Transactions,  vol.  iii. 


DISEASES    OE    THE    BRAES'    AND    SPINAL    COT,D.  109 

contractility.  But  here  again  we  must  remember  that  the  con- 
tinuous current  may  give  different  results  from  faradization. 
Meyer  tells  us  that  those  facial  palsies  in  which,  a  week  after 
their  appearance,  faradization  produces  no  muscular  movement, 
while  a  feeble  continuous  current  causes  vigorous  contractions  in 
the  muscles,  furnish  a  much  more  unfavorable  prognosis,  and 
recover  slowly  and  imperfectly.  He  supposes  the  lesion  to  be  in 
the  facial  nerve  while  passing  through  the  petrous  portion  of  the 
temporal  bone. 

In  rare  instances  the  facial  palsy  is  seen  on  both  sides.  Now, 
the  disorder  may  be  within  the  cranium  or  may  affect  the  nerves 
in  their  course.  When  dependent  simply  on  a  local  affection,  and 
therefore  limited  to  the  manifestations  of  paralysis  of  the  portio 
dura,  we  find  the  same  causes  at  work  which  give  rise  to  the  one- 
sided disease.  Exposure  to  cold  and  rheumatism  are  the  most 
frequent;  but  syphilis  is  also  among  the  causing  elements.  In  an 
instance  detailed  by  Todd  in  his  clinical  lectures,  in  which  there 
was  disease  of  the  temporal  bone,  the  portio  mollis  was  also  im- 
plicated. The  face  is  immovable,  or  nearly  so,  and  the  palsy  is 
generally  more  complete  on  the  left  side  than  on  the  right.  The 
muscles  do  not  respond  to  electricity,  or  respond  imperfectly,  and 
we  notice,  as  in  the  one-sided  malady,  that  a  continuous  current 
may  excite  their  action,  while  faradization  does  not.  Nay,  the 
two  sides  may  give  different  results  in  this  respect.* 

Paralysis  of  the  radial  nerve  is  another  form  of  local  palsy 
often  encountered.  It  may  happen  from  rheumatism ;  but  its 
most  common  cause  is  compression.  A  person  falls  asleep  with 
his  head  on  his  arm,  and  a  temporary  palsy  results.  In  truth, 
the  disorder  may  be  taken  as  the  type  of  the  palsies  by  com- 
pression, and  we  find  here,  therefore,  the  rule,  which  is  thought 

*  Case  of  Baerwinkel.  Schmidt's  Jahrb.,  Bel,  exxxvi.  Xo.  1.  Baerwinkel 
suggests  that  the  dissimilar  reaction  is  always  owing  to  different  exudation 
and  condition  of  pressure  on  the  affected  nerve.  Thus,  in  any  case,  whether 
single  or  double,  where  galvanization  produces  contraction,  and  the  induced 
current  fails  to  do  so,  he  thinks  that  a  firm  and  extensive  exudation  compresses 
the  nerve,  whereas  in  slight  or  serous  exudations  faradization  acts,  and  a 
speedy  recovery  may  be  anticipated. 

For  other  cases  of  double  facial  palsy,  see  Gairdner,  Lancet,  May  18,  1861  ; 
Pellet,  Travaux  de  la  Societe  Medicale,  1867;  "Wright,  British  Medical  Jour- 
nal, Feb.  1869. 


110  MEDICAL    DIAGNOSIS. 

by  some  to  be  invariable  in  this  class  of  palsies,*  that  the  electro- 
muscular  contractility,  even  when  the  loss  of  voluntary  motion  is 
complete,  is  preserved  or  only  diminished,  not  abolished.  This 
guide  is  of  great  use  in  the  differential  diagnosis  of  forearm  palsy 
from  lead.  Here  we  find,  in  addition,  that  the  supinator  longus 
escapes,  while  it  always  loses  its  power  in  the  radial  palsy  from 
compression. 

About  other  local  palsies,  as  of  the  pharynx  and  oesophagus,  of 
the  larynx,  of  one  side  of  the  palate,  f  of  the  tongue,  of  the  mus- 
cles of  the  eye,  of  the  diaphragm,  of  isolated  muscles  of  the  trunk 
and  of  the  extremities,  it  is  impossible  here  to  enter  into  partic- 
ulars. But  there  are  some  forms  of  local  palsy  which,  from  their 
striking  interest,  it  is  necessary  to  describe.  One  is  the  loss  of 
power  in  the  wrists,  arising  from  atrophy  of  the  muscles  in  the 
overworked  parts,  occurring  in  persons  whose  stomachs  do  not 
take  in  a  sufficient  supply  of  nutriment,  as  in  poorly-fed  and 
hard-worked  shoemakers  ;J  another  is  the  paralysis  of  the  tongue 
and  parts  concerned  in  deglutition,  to  which  attention  has  been 
chiefly  called  by  Trousseau. 

In  this  glosso-labio -laryngeal  paralysis,  the  first  symptoms 
which  are  likely  to  attract  attention  are,  that  the  tongue  seems 
less  supple  and  the  utterance  becomes  nasal  or  thick ;  the  food 
lodges  between  the  teeth  and  cheek,  and  the  saliva  dribbles  from 
the  lips  and  corners  of  the  mouth.  As  the  paralysis  progresses, 
articulate  speech  is  almost  lost ;  the  shape  of  the  tongue  is  altered, 
it  dwindles,  and  at  times  shows  twitching  of  its  fibres,  or  lies 
motionless  in  the  mouth,  though  it  reacts  to  faradization  ;  the  pos- 
terior nares  can  no  longer  be  closed  by  the  velum  and  muscles  of 
the  posterior  palatine  arch  ;  deglutition  becomes  very  difficult,  and 
the  patient  is  tormented  with  hunger.  The  mucous  membrane  of 
the  larynx  is  frequently  insensible;  the  respiratory  movements 
are  unusually  weak,  and  fits  of  suffocation  ensue.  The  general 
debility  becomes  extreme,  and  the  patient  is  apt  to  perish  by  the 
sudden  stoppage  of  the  heart's  action.     The  disease  is  unmistaka- 

*  Chapoy,  quoted  in  Arch.  Gen.  de  Med.,  Sept.  1874.  See  also  cases  of  radial 
paralysis  by  Panas,  ib.,  June,  1873. 

f  Fully  described  by  Dumenil,  Arch.  Gen.  de  Med.,  April,  1875,  and  traced, 
for  the  most  part,  to  a  central  lesion. 

J  Chambers  on  the  Indigestions. 


DISEASES    OF    THE    BEAIN    AND    SPINAL    COED.  Ill 

ble.  Double  facial  palsy  resembles  it  most;  but  here  the  tongue 
is  not  involved,  and  the  eyelids  remain  open ;  on  the  other  hand, 
in  glosso-laryngeal  paralysis  only  the  lower  part  of  the  face  is 
motionless.  This  curious  malady  may  have  an  acute  beginning, 
and  seemingly  in  cold ;  it  is  sometimes  complicated  with  weak- 
ness of  the  muscles  of  one  side  of  the  body.  It  is  most  generally 
of  slow  development  and  slow  but  relentless  progress.  The  af- 
fection, called  by  the  Germans  "progressive  bulbar  paralysis,"  has 
its  seat  of  lesion  in  the  medulla  oblongata,  in  the  motor  elements 
of  the  gray  constituents,  which  undergo  a  degenerative  atrophy ; 
and  we  understand  the  main  symptoms  when  we  reflect  on  the 
nuclei  which  connect  the .  hypoglossal,  the  spinal  accessory,  the 
vagus,  and  the  facial. 

Now,  before  passing  on  to  other  matters,  we  shall  discuss  a  few 
points  of  general  clinical  interest.  We  are  sometimes  much  per- 
plexed to  know  if  a  palsy  be  the  result  of  commencing  disease  of 
the  brain  or  spinal  cord,  or  if  it  be  purely  local.  To  speak  first  of 
the  brain :  the  cerebral  symptoms  may  not  be  marked,  or  they 
may  be  so  contradictory  as  to  afford  no  real  help  in  diagnosis. 
We  may  have  nothing  to  fall  back  upon  but  our  knowledge  of 
the  anatomy  and  physiology  of  the  nervous  system ;  and  if  we 
discover  that  the  palsy  affects  muscles  that  are  supplied  by  differ- 
ent nerves  and  such  as  have  no  communication  with  one  another, 
we  may  set  down  the  complaint  as  having  a  central  origin. 

Another  important  question  which  may  arise — and  with  refer- 
ence not  only  to  limited  but  also  to  extended  palsies — is,  whether 
the  loss  of  muscular  power  be  not  in  reality  dependent  upon 
changes  in  the  muscular  tissue,  and  especially  upon  that  change 
found  in  the  disorder  known  as  "  wasting  palsy,"  or  progressive 
muscular  atrophy.  Concerning  the  nature  of  this  strange  affection 
we  are  as  yet  in  doubt.  It  was  once  thought  to  be  owing  to  a  dis- 
ease of  the  anterior  roots  of  the  spinal  nerves ;  but  the  researches 
of  Aran  led  to  the  opinion  that  it  consists  in  an  atrophy  connected 
with  fatty  transformation  of  the  muscular  fibres,  due  primarily  to 
changes  of  these  structures.  Still,  though  this  view  would  seem 
to  be  favored  by  the  cases  analyzed  by  Roberts,*  and  has  been,  at 
least  as  regards  the  peripheral  origin  of  the  malady,  reaffirmed 

*  Essay  on  Wasting  Palsy. 


112  MEDICAL    DIAGNOSIS. 

lately  in  an  elaborate  treatise  by  Friedrich,*  it  is  very  possible 
that,  by  patient  and  careful  examinations  of  the  spinal  cord,  we 
shall  find  minute  structural  changes  in  its  substance  confined  to 
isolated  spots,  and  sufficient  to  account  for  the  disease  in  the  mus- 
cles. This  was  done  by  Lockhart  Clarke,  f  Numerous  observers, 
especially  Charcot,  have  shown  degenerative  changes  in  the  gray 
substance  of  the  cord,  particularly  in  the  large  ganglion  cells  of 
the  anterior  horns.  ShawJ  has  minutely  examined  a  case  in  which 
coexisting  sclerosis  of  the  lateral  columns  was  found;  and,  on  the 
whole,  the  connection  with  the  nervous  lesion  is  too  constant  for 
us  to  look  upon  it  as  a  coincidence. 

The  most  striking  sign  of  progressive  muscular  atrophy  is 
increasing  inability  to  perform  certain  movements.  When  the 
muscle  chiefly  concerned  in  the  attempted  motion  is  examined,  it 
is  found  to  have  dwindled.  Soon  other  muscles  follow;  and  their 
wasting,  too,  is  accompanied  by  still  further  impaired  motion. 
Portions  of  the  disorganizing  muscles  twitch,  much  to  the  annoy- 
ance of  the  patient.  The  circulation  in  the  affected  part  becomes 
languid ;  it  is  also  very  susceptible  to  cold,  and  indeed  its  temper- 
ature is  lowered ;  there  is  a  feeling  of  numbness  in  it,  but  rarely 
pain ;  to  pressure  it  is  soft  and  yielding.  The  muscles  most  fre- 
quently attacked  are  those  of  the  hand  ;  the  flexors  and  supinators 
of  the  forearm ;  the  biceps,  the  deltoid,  and  the  other  muscles  of 
the  shoulder;  sometimes  the  disease  begins  in  the  trunk  and 
lower  extremities.  The  decrease  of  the  muscular  fibres  gives  rise 
to  strange  and  palpable  deformities,  and,  when  the  muscles  of  the 
trunk  are  involved,  to  extraordinary  positions  of  the  body,  in 
consequence  of  all  antagonism  to  the  healthy  muscles  having  been 
removed. 

When  we  contrast  this  curious  malady  with  the  forms  of  paral- 
ysis with  which  it  may  be  confounded,  we  find  several  features  at 
variance.  From  cerebral  hemiplegia  it  differs  by  its  much  more 
gradual  invasion,  by  the  rapidity  but  want  of  uniformity  with 
which  the  muscular  atrophy  takes  place,  and  by  the  absence  of  dis- 
ordered intellect  and  of  other  signs  of  disease  of  the  brain.  From 
extended  general  paralysis  of  cerebral  origin  it  is  separated  by  the 

*  Progressive  Muskelatrophie,  etc.,  Berlin,  1874. 

f  Beale's  Archives  for  1861. 

J  Journal  of  Nervous  and  Mental  Diseases,  Chicago,  Jan.  1879. 


DISEASES    OF    THE    BRAIN    AND    SPINAE    CORD.  113 

non-existence  of  cerebral  phenomena,  and  by  the  capricious  and 
unequal  manner  in  which  the  atrophy  seizes  upon  the  muscles. 
Difficulty  in  articulation  and  in  deglutition  may  occur  in  either; 
but  in  the  one  case  they  are  associated  with  disturbed  mental  facul- 
ties, in  the  other  they  are  not.  From  general  spinal  paralysis  it 
is  mainly  diagnosticated  by  the  spinal  malady  affecting  primarily 
all  the  muscles  of  the  lower  extremities  before  those  of  the  upper 
become  involved. 

Another  means  of  distinguishing  the  muscular  atrophy  from 
the  diseases  just  considered,  is  by  means  of  instruments  by  which 
portions  of  the  affected  textures  can  be  removed  and  subjected  to 
microscopical  examination.  Duchenne  has  invented  a  trocar  for 
the  purpose,  and  so  have  other  pathologists.* 

Then  we  possess  a  touchstone  in  the  use  of  electricity.  In  pro- 
gressive muscular  atrophy  the  muscles  respond  feebly,  still  they 
respond;  and  in  portions  where  there  are  many  sound  fibres  they 
contract  energetically.  In  general  paralysis  of  spinal  origin  their 
contractile  power  is  lost;  no  effort  of  the  patient,  no  current,  causes 
them  to  move.  In  general  cerebral  paralysis,  on  the  other  hand, 
their  electrical  contractility  is  intact.  The  difficulty  of  distinguish- 
ing cases  of  local  paralysis  from  progressive  muscular  atrophy  is 
at  times  very  great.  Yet  generally  we  may  separate  the  latter, 
say,  for  instance,  from  rheumatic  paralysis,  by  noticing  that  this 
affects  a  group  of  muscles  rather  than  one  muscle,  or  than  one 
muscle  here  and  another  there.  Further,  the  atrophied  muscle  in 
the  rheumatic  disorder  is  the  seat  of  pain  intensified  by  movement, 
and  it  contracts  well  under  the  electric  stimulus, — phenomena  not 
presented  by  muscular  textures  which  have  undergone  fatty  trans- 
formation. The  same  test  by  the  electric  current  is  of  service  in 
discriminating  the  muscular  disease  from  hysterical  paralysis,  from 
paralysis  consequent  upon  injuries  to  nervous  trunks  and  upon 
lead  poisoning.  In  the  first  of  these  palsies  the  electrical  con- 
tractility is,  except  temporarily  in  old  standing  cases,  intact,  in 
the  others  it  is  abolished ;  while  in  progressive  muscular  atrophy 
it  is  simply  enfeebled. 

The  most  difficult  differential  diagnosis  we  may  be  called  upon 
to  make  is  to  distinguish  certain  cases  of  progressive  muscular 

*  For  an  exact  description  of  these  different  instruments,  see  Amer.  Journ. 
of  Med.  Sciences,  Oct.  1869,  p.  434. 


114  MEDICAL    DIAGNOSIS. 

atrophy  from  glosso-labio-laryngeal  paralysis.  In  truth,  the  two 
affections  often  coexist,  ami  the  features  of  each  may  be  blurred  to 
the  last  degree.  In  acute  cases  we  are  helped  by  the  more  rapid 
development  of  the  paralysis  in  the  latter  malady, — sometimes 
occurring  as  it  does  in  a  few  days, — and  without  at  first  that  pro- 
portional reduction  in  the  size  and  strength  of  the  muscle  which 
we  find  in  progressive  muscular  atrophy.  In  chronic  cases  the 
diagnosis  may  be  at  first  very  difficult  should  the  progressive 
muscular  atrophy  be  limited.  But  we  must  remember  that  in  this 
disease  the  muscles  act  under  electricity;  while,  as  Friedrich  tells 
us,  electro-muscular  contractility,  both  direct  and  reflected,  is  lost 
in  the  glosso-laryngeal  palsy. 

Paralyzed  muscles  atrophy,  and,  as  especially  happens  in  chil- 
dren, may  subsequently  undergo  a  fatty  change.  To  distinguish 
such  a  condition  from  progressive  muscular  atrophy  is  not  easy. 
>Ve  have  to  lay  stress  on  the  symptoms  which  ushered  in  the 
paralytic  state. 

This  is  particularly  important  in  attempting  to  discriminate  with 
reference  to  the  so-called  essential  paralysis  from  which  children 
suffer ;  for  we  attach  great  weight  to  the  fever  and  the  convul- 
sions and  other  cerebral  symptoms  so  commonly  preceding  the 
palsv,  or  to  its  occurring  suddenly  during  teething.  Besides,  an 
entire  limb,  or  even  both  legs  and  arms,  may  from  the  onset  be 
affected.  And  this  becomes  plainly  discernible  as  the  fever  sub- 
sides. Yet  the  palsy  at  first  shifts;  it  disappears  from  some  limbs, 
or  fixes  upon  others  or  upon  different  groups  on  different  sides  of 
the  body.  It  rarely,  however,  remains  as  palsy  of  more  than  one 
side,  and  is  not  associated  with  loss  of  sensibility.  There  is  often 
recoverv  within  six  months  from  its  onset;  though  the  disorder 
may  last  for  three  or  four  years,  or  even  much  longer.  The  af- 
fected muscles  are  apt  to  begin  to  atrophy  after  the  paralysis  has 
lasted  a  month,  and  when  their  wasting  is  marked  they  no  longer 
respond  to  the  induced  electrical  current,  though  they  may  still 
react  strongly  under  the  constant  galvanic 'current.*  In  protracted 
cases,  contraction  of  the  joints  takes  place,  and  atrophy  of  por- 
tions of  the  osseous  system  occurs,  or  rather  a  want  of  its  devel- 
opment in  the  blighted  parts. 

*  Hammond's  Journal  of  Psychology,  vols.  i.  and  ii. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  115 

Now,  the  onset  of  these  cases, — not,  let  us  state  in  passing,  the 
only  kind  of  palsy  met  with  in  children, — the  occasional  retroces- 
sion from  certain  parts,  the  subsequent  course,  and  the  electrical 
reactions,  separate  it  from  progressive  muscular  atrophy.  Then  in 
forming  a  diagnosis  we  may  take  into  account  the  extreme  rarity 
with  which  children  are  attacked  with  progressive  muscular 
atrophy, — a  disease  of  adults,  and  pre-eminently  of  those  of  the 
male  sex  who  use  their  muscles  continuously  and  violently.  But 
the  affection  may  happen  in  children,  and  then,  as  Duchenne 
points  out,  is  apt  to  show  itself  first  in  the  muscles  around  the 
mouth.  On  the  other  hand,  we  must  not  forget  that  a  disease 
identical  with  the  essential  palsy  of  children  is  met  with  in  adults. 
Beginning  acutely  with  febrile  symptoms,  headache,  delirium,  and 
pain  in  the  back,  it  leads  within  a  few  days  or  less  to  palsy  with 
complete  relaxation  of  the  paralyzed  muscles,  yet  without  im- 
paired sensibility,  exhibits  but  passing  vesical  disorder,  but  shows 
soon  disappearance  of  reflex  irritability  and  wasting  of  the  limbs, 
and  has  the  lesion  which  has  been  found  in  infantile  palsy,  granular 
degeneration  of  the  cells  of  the  anterior  horns.  This  acute  ante- 
rior spinal  paralysis  is,  however,  not  common;  although  it  is  not 
as  uncommon  as  formerly  supposed,  and  under  the  title  of  acute 
anterior  poliomyelitis  we  are  becoming  more  and  more  familiar 
with  its  clinical  history,  and  are  learning  how  often  complete  or 
nearly  complete  recovery  from  the  threatening  symptoms  takes 
place.* 

The  difference  in  age  helps  us  also  to  distinguish  that  curious 
disorder,  chiefly  described  by  Duchenne,  which  he  names  pseudo- 
hypertrophic muscular  paralysis.  A  disease  exclusively  of  child- 
hood, it  is  characterized  by  weakness  in  the  lower  limbs  primarily, 
the  muscles  of  which,  and  particularly  the  calves,  increase  greatly 
in  size.  Yet,  notwithstanding  this  apparent  hypertrophy,  there 
is  debility,  with  a  waddling  gait,  and,  as  the  disease  progresses 
and  becomes  more  general,  complete  paralysis  may  ensue,  with 
rapid  dwindling  of  the  affected  muscles.  These,  when  examined 
microscopically,  show,  in  the  stage  of  increase,  large  masses  of 

*  See  literature  and  cases  recorded  by  Seguin,  Trans.  New  York  Acad,  of 
Med.,  1874,  and  "Myelitis  of  the  Anterior  Horns, ';  1877;  Sinkler,  Amer. 
Journ.  of  Med.  Sciences,  October,  1878;  Althaus,  ib.,  April,  1878;  and  Erb, 
vol.  xiii.  of  Ziemssen's  Cyclopaedia. 


116 


MEDICAL    DIAGNOSIS. 


interstitial  fatty  matter  and  an  augmentation  of  the  interstitial 
connective  tissue. 

There  is  another  disease  resembling  progressive  muscular  atrophy 
which  may  be  here  alluded  to,  the  singular  affection  endemic  in 
parts  of  Japan,  known  there  as  Kakhe,  and  probably  identical 
with  the  disease  called  in  India  and  Brazil  "  Beriberi."  This 
dangerous  malady  is  a  non-febrile  recurrent  affection,  seemingly 
caused  by  overcrowding,  and  having  as  its  chief  symptoms  exten- 
sive anaesthesia  ;  general  loss  of  muscular  power,  amounting  in  the 
lower  extremities  to  paralysis ;  diminished,  but  not  lost,  electro- 
muscular  contractility;  marked  progressive  muscular  atrophy  in 
the  legs;  dropsical  effusion;  reflex  vomiting;  palpitation  and 
often  failure  of  the  circulation.* 

Before  proceeding,  we  will  examine  the  main  forms  of  paralysis 
which  we  have  been  studying,  arranged  in  a  tabular  form,  and 
chiefly  with  the  view  of  ascertaining  the  seat  of  lesion,  premising 
that  the  statements  must  be  received  rather  as  generally  true  than 
as  absolutely  so. 

TABULAE   VIEW    OF   PAEALYSIS. 


Symptoms. 
Inability  to  move  leg  and  arm  of 
one  side.  Sensation  unimpaired, 
or  slightly  impaired.  Incomplete 
paralysis  of  muscles  of  face  ;  mouth 
drawn  toward  healthy  side.  Elec- 
tro-muscular contractility,  as  a  rule, 
preserved  ;  may  be  increased. 

Same  symptoms,  but  paralysis  efface 
on  opposite  side  to  that  of  arm  and 
leg,  and  usually  marked  facial  palsy; 
loss  of  sensation  on  one  side  of  face ; 
giddiness  ;  nausea,  etc. 


Seat  of  L< 
Corpus  striatum  chiefly,  less  markedly 
optic  thalamus,  both  on  side  oppo- 
site to  the  palsy. 


Pons  Varolii,  on  side  opposite  to  palsy 
of  limbs.  The  part  affected  is  be- 
low decussation  of  facial  nerve. 


Same  symptoms,  but  face  paralyzed  Pons  Varolii,  and  at  level  of  decussa- 

on  both  sides.  tion  of  facial  nerve. 

Paralysis  of  arm  and  leg  on  one  side  ;  Crus  cerebri  on  side  corresponding  to 

slight  paralysis  of  face  :  third  nerve  paralysis  of  third  nerve, 
paralyzed  on  other  side. 


Anderson,  St.  Thomas's  Hospital  Reports,  1876. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD. 


117 


Paralysis  of  motion  of  arm  and  leg, 
incomplete  and  transitory,  soon  fol- 
lowed by  rigidity  ;  no  loss  of  sensa- 
tion. 


Cortical  part  of  brain  in  motor  zone, 
on  side  opposite  to  palsy. 


Paralysis  of  one  arm  and  the  same  Middle  or  lower  third  of  the  ascend- 
side  of  the  face,  sensation  unim-  ing  convolutions  in  facial  and 
paired;  if  palsy  right-sided,  aphasia.         manual   centres,   on   side   opposite 

to  palsy. 


Medulla  oblongata  on  side  of  in- 
creased sensibility  and. temperature, 
and  at  level  of  decussation  of  ante- 
rior pyramids. 

In  the  cord  throughout  its  sections 
at  upper  limit  of  lumbar  region,  or 
higher  up. 


Motion  more  or  less  completely 
affected  on  both  sides  of  body ; 
sensibility  diminished  or  lost  on 
one  side,  increased  on  the  other ; 
the  same  with  temperature. 

Both  legs  paralyzed  as  to  motion  and 
sensation.  Paralysis  of  muscles  of 
respiration  ;  loss  of  power  over  blad- 
der and  rectum  ;  reflex  excitability 
greatly  diminished  or  lost ;  electro- 
muscular  contractility  diminished 
or  lost. 

Both  legs  paralyzed  as  to  sensation 
and  motion,  except  muscles  supplied 
by  anterior  crural  and  obturator 
nerves  ;  loss  of  power  over  bladder 
and  rectum ;  reflex  excitability 
greatly  diminished  or  lost. 

Both  legs  paralyzed  as  to  motion,  sen- 
sation unimpaired ;  loss  of  power 
over  bladder  and  rectum  ;  muscular 
rigidity  ;  reflex  movements  and  ten- 
don reflexes  increased  ;  impaired, 
not  lost,  electro-muscular  contrac- 
tility. 

Both  legs  paralyzed  as  to  motion, 
relaxation  of  muscles,  sensation 
unimpaired,  only  passing  loss  of 
control  over  bladder  and  rectum ; 
extinction  of  reflex  excitability  ; 
lost  electro-muscular  contractility 
to  faradaic  current ;  rapid  muscular 
atrophy. 

Locomotor  Ataxia. — In  this  disorder  we  have  uncertainty 
of  motion  and  apparent  palsy ;  or,  in  the  words  of  Duchenne, 
who  gave  it  the  name  of  progressive  disorder  of  locomotion, — 


In  the  cord  throughout  its  sections 
at  upper  limit  of  sacral  region. 


Anterior  lateral  columns  of  the  cords, 
as  in  sclerosis  of  these  parts. 


Anterior  horns  of  the' cord,  as  in  de- 
generation of  the  cells  in  poliomye- 
litis. 


118  MEDICAL    DIAGNOSIS. 

a t<i. vie  locomotriee  progressive, — it  consists  in  "a  progressive  abo- 
lition of  the  co-ordination  of  movement  with  apparent  paralysis 
contrasting  with  the  integrity  of  muscular  force."  The  patient 
is  not  deprived  of  the  power  of  motion,  but  of  the  power  of 
controlling  his  motion  :  hence  he  staggers  in  his  walk,  or  cannot 
walk  at  all  without  support;  it  is  evident  that  the  muscles  do  not 
obey  the  will. 

Locomotor  ataxia  is  identical  with  a  form  of  palsy  clearly 
recognized  by  Todd,  and  with  the  malady  described  by  Romberg 
as  tabes  dor sails  ;  from  the  lesion  it  exhibits,  it  is  often  called  pos- 
terior sclerosis,  degeneration  of  the  posterior  columns,  especially 
in  the  lumbar  region,  being  its  main  cause. 

The  affection  is  a  very  chronic  one,  lasting  many  years.  It 
originates  without  assignable  cause;  or  it  may  follow  exposure  to 
cold,  or  injury  or  inflammation  of  the  cord;  or  it  results  from  syph- 
ilis; or  it  is  hereditary.  Among  its  early  symptoms  are  piercing 
pains,  lightning-like,  or  similar  to  electric  discharges,  in  the  lower 
extremities;  disturbances  of  vision,  which  may  be  found  to  be 
attended  with  small  almost  motionless  pupils,*  or  with  paralysis 
of  the  sixth  or  the  third  pair;  vertigo;  and  a  zone  in  which 
sensation  is  greatly  impaired,  on  a  level  with  the  third,  fourth, 
fifth,  or  sixth  dorsal  vertebra.f  Following  these  phenomena,'  or, 
it  may  be,  making  its  appearance  at  the  same  time,  is  a  peculiar 
difficulty  in  co-ordinating  movements  and  in  maintaining  the  equi- 
librium of  the  body.  This  is  especially  manifest  in  attempting 
to  walk  or  even  to  stand  with  the  eyes  closed,  and  the  patient  is 
unable  to  take  a  single  step,  or  to  stand  erect  with  his  feet  in  jux- 
taposition, without  instantly  losing  his  balance.  True,  this  sign 
is  not  strictly  pathognomonic,  but  it  is  very  valuable  in  the  diag- 
nosis of  the  earlier  stages,  and  so  is  the  difficulty  he  has  in  placing 
the  foot  on  small  surfaces,  or  in  buttoning  his  clothes.  Yet  the 
stumbling,  staggering  gait  is  not  connected  with  true  paralysis. 
The  muscles  can  act  vigorously,  are  well  nourished,  contract  readily 
when  faradized,  except  in  very  advanced  stages  of  the  disease, 
and  show  neither  tremor  nor  spasm.  Sensibility  is  markedly 
diminished,  pinching  and  pricking  the  foot  may  scarcely  be  felt, 
the  contact  with  the  floor  not  be  appreciated,  and  the  tactile  sen- 

*  Jonathan  Hutchinson,  "  Brain,"  July,  1878. 

f  Hitzig,  in  Ziemssen's  Cyclopaedia,  article  "  Atrophy  of  Brain.'' 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  119 

sibility  be  almost  gone;  but  all  kinds  of  curious  sensations  in  the 
feet  are  complained  of:  the  power  to  appreciate  differences  of  tem- 
perature may,  though  it  does  not  always,  remain.  The  intellect 
is  unimpaired,  unless  frequent  attacks  of  vertigo  and  epileptic 
seizures  should  be  among  the  symptoms.  The  eyesight  fails  more 
and  more,  and  an  atrophy  of  the  optic  nerve,  dependent  most 
likely  also  upon  sclerosis,  produces  irremediable  distress  in  vision  ; 
the  hearing,  too,  may  become  much  affected.  The  functions  of 
the  rectum  and  bladder  are  not  disordered.  In  the  last  stages  the 
muscles  are  atrophied,  dropsy  is  met  with,  and  so  are  cutaneous 
eruptions  and  swelling  of  the  joints,  without  redness  or  pain. 
But  the  joint  affection  may  appear,  as  Charcot  has  taught  us, 
before  the  loss  of  power  of  co-ordinating  movement.  In  time  the 
articular  extremities  of  the  bones  disappear,  and  the  joints  undergo 
a  kind  of  dislocation. 

To  turn  to  a  consideration  of  the  diagnosis  of  the  malady 
under  discussion.  Let  us  first  examine  how  it  differs  from  the 
general  paralysis  of  the  insane.  Both  maladies  are  very  chronic 
in  their  course,  and  in  both  there  is  loss,  or  certainly  impairment, 
of  the  faculty  by  which  we  co-ordinate  the  action  of  the  muscles. 
In  the  one  case,  however,  it  exists  with  tremors,  with  thickness  of 
speech,  with  dementia,  and,  at  least  in  its  earlier  stages,  with  a 
certain  amount  of  force  in  the  irregular  muscular  movements; 
but  without  strabismus,  without  defective  vision,  and  without  the 
sharp,  peculiar  pains  of  ataxia.  Then,  in  this  malady,  the  upper 
extremities  share  far  less  frequently  in  the  disorder,  and  when 
they  do,  there  is  in  them  rather  cutaneous  anaesthesia  with  some 
trembling  and  incomplete  paralysis,  than  an  obvious  failure  of 
co-ordinating  power. 

With  reference  to  the  distinction  of  progressive  locomotor  ataxia 
from  most  of  the  diseases  of  the  spinal  cord,  it  is  only  necessary 
to  remark  on  the  extreme  rarity  of  muscular  spasm  in  ataxia; 
from  spinal  paraplegia  the  result  of  myelitis  it  differs  in  the  fact 
that  the  muscles  act  with  strength,  the  patient  can  flex  and  ex- 
tend his  legs  and  kick  vigorously,  while  in  paralysis  the  affected 
limbs  cannot  move.  Anterolateral  sclerosis  differs  broadly  by 
the  absence  of  the  neuralgic  pains,  by  the  absence  of  signs  of  de- 
ranged balancing  power,  and  by  the  well-preserved  co-ordination  of 
the  movements  on  closing  the  eyes.     The  same  points,  in  addition 


120  MEDICAL    DIAGNOSIS. 

to  the  tremor,  distinguish  disseminated  cerebro-spinal  sclerosis. 
But  we  must  not  overlook  the  possibility  of  mixed  symptoms 
existing  from  the  different  forms  of  sclerosis  being  combined. 

A  diminution  or  loss  of  the  muscular  sense — that  guiding  sense 
by  which  we  judge  of  the  position  of  the  limbs,  of  the  degree  of 
resistance  opposed  to  muscular  movements,  and  are  conscious  of 
these  movements,  and  which,  particularly  in  hysterical  patients, 
may  become  much  disturbed — occasions  difficulty  in  diagnosis, 
since  in  locomotor  ataxia  the  muscular  sense  may  be  also  deficient, 
and,  on  the  other  hand,  in  the  former  morbid  state  the  motion 
may  be  somewhat  impaired,  and,  as  in  ataxia,  the  feet  may  feel 
numb  in  standing  and  in  walking,  and  the  patient  be  unable  to 
walk  in  the  dark.  But  there  is  this  difference  :  where  merely  the 
muscular  sense  is  affected,  he  can  walk  and  perform  all  move- 
ments, even  those  of  a  complex  nature,  without  vacillation,  so 
long  as  his  eye  is  fixed  on  them  and  superintends  and  gives  them 
direction;  Avhile  in  ataxia  the  derangement  of  muscular  co-ordi- 
nation renders,  even  with  the  aid  of  sight,  the  movements  uncer- 
tain and  irregular.  Then  cutaneous  anaesthesia  is  apt  to  coexist 
with  this  malady;  and  the  treatment  will  throw  light  on  a  doubt- 
ful case:  the  local  use  of  electricity  will  usually  cure  the  loss  of 
muscular  sense  in  hysterical  paralysis ;  it  has  no  curative  effect  in 
ataxia. 

Diseases  of  the  cerebellum  produce  many  of  the  phenomena  re- 
garded as  peculiar  to  locomotor  ataxia.  But  the  gait  of  the  patient 
is  precisely  that  of  a  drunken  man  :  when  attempting  to  walk,  he 
leans  to  one  side,  moves  in  arcs  of  a  circle,  or  describes  zigzags; 
and  when  standing  erect,  his  body  swings  backward  and  forward, 
or  from  side  to  side,  though  his  feet  remain  quietly  fixed  on  the 
ground.  In  ataxia,  on  the  other  hand,  the  muscular  contractions 
in  the  erect  position  or  during  attempts  at  walking  are  strong  and 
sudden,  more  like  spasms,  yet  not  spasmodic,  and  have  as  their 
object  to  keep  the  body  in  the  line  of  gravity;  and  the  walk, 
though  accomplished  with  difficulty,  is  straight,  not  reeling;  the 
affected  person,  too,  while  he  is  walking,  does  not  take  his  eyes  off 
the  ground  or  off  his  feet,  from  fear  of  falling;  but  he  is  not 
giddy.  In  diseases  of  the  cerebellum  we  find  decided  vertiginous 
sensations,  especially  during  attempts  at  locomotion,  which  may 
be  easier  and  straighter  with  the  eyes  shut  than  with  them  open  ; 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  121 

vomiting,  particularly  at  the  onset  of  the  complaint,  aggravated 
or  brought  on  by  the  erect  posture ;  severe  headache,  occipital  or 
frontal,  when  the  head  is  bent ;  defective  vision,  becoming  very 
marked  when  an  object  is  looked  at  for  any  length  of  time,  or 
double  vision,  though  the  eye-disturbances  may  or  may  not  be 
associated  with  choked  disk  or  optic  neuritis;  no  diminution 
either  of  power  of  motion  or  of  sensibility  ;  and  in  some  instances 
rotary  movements  and  hemiplegia.  When  the  disease  is  localized 
in  one  hemisphere  of  the  cerebellum,  it  may  cause  no  symptoms 
and  be  beyond  the  reach  of  diagnosis.* 

Chronic  alcoholism  gives  rise  to  extended  hypersesthesia  and 
neuralgic  pains,  and  to  motor  disturbances  like  those  of  ataxia.f 
But  in  the  history  and  in  the  other  evidences  of  the  ravages  of 
alcohol  we  find  the  distinguishing  traits.  In  chorea  the  irregular 
muscular  movements  are  very  dissimilar  from  those  of  locomotor 
ataxia,  and  there  is  an  absence  of  the  neuralgic  pains.  Moreover, 
chorea  is  mainly  a  disease  of  childhood ;  locomotor  ataxia,  of  adults. 
The  greatest  similarity  to  locomotor  ataxia  I  have  seen  has  been 
in  several  cases  of  hysteria ;  one  in  particular,  in  a  very  ansemie 
woman,  resembled  it  closely ;  and  it  may  be  a  question  whether 
the  nutrition  of  the  parts  affected  in  ataxia  were  not  disordered, 
and  the  nervous  structures  functionally  disturbed.  I  desire  partic- 
ularly to  call  attention  to  these  cases,  which  can  be  distinguished 
by  their  history,  the  usual  coexistence  of  anaemia,  and  the  ab- 
sence of  severe  darting  pains.  Yet  pains  may  also  happen  in  the 
hysterical  complaint,  as  in  a  case  I  saw  with  Dr.  Webb  ;J  but 
this  is  uncommon.  Moreover,  the  apparent  want  of  muscular  co- 
ordination is  more  irregular  in  its  manifestations  ;  and  the  cases 
recover.  So,  I  think,  may  other  cases  of  locomotor  ataxia  due  to 
special  causes.  For  I  have  seen  cases  in  syphilitic  patients,  typical 
in  everything  except  perhaps  the  severity  of  the  neuralgic  pain, 
essentially  typical  in  the  muscular  phenomena  and  in  the  inability 
to  walk  with  closed  eyes,  in  which  a  gradual  and  nearly  complete 
recovery  took  place.  Here  the  lesion  was  probably  removed  or 
greatly  influenced  by  the  anti-syphilitic  treatment. 

Tremor. — Any  involuntary  agitation  of  the  body,  or  of  part 

*  Nothnagel,  Berliner  Klinische  Wochenschrift,  April,  1878. 
|  Leudet,  Archives  Generales  de  Medecine,  Jan.  1867. 
X  American  Journal  of  the  Medical  Sciences,  Jan.  1876. 


122  MEDICAL    DIAGNOSIS. 

of  it,  without  marked  muscular  contraction  or  impediment  to 
voluntary  movement,  is  called  tremor.  The  trembling  depends 
upon  a  weakening  of  the  muscular  and  nervous  systems.  It  is 
common  in  old  age,  in  convalescence  from  debilitating  diseases, 
and  during  chills.  We  also  find  it  in  workers  in  mercury  or  in 
lead,  and  in  those  who  abuse  alcoholic  stimulants  or  coffee,  or  who 
are  addicted  to  the  use  of  opium.  In  some  cases  it  is  connected 
with  an  organic  disease  of  the  nervous  centres;  and  it  constitutes 
the  main  symptom  of  the  disorder  known  as  shaking  palsy  or 
paralysis  agitans. 

Tremor  is  easily  recognized.  Yet  it  may  be  confounded  with 
muscular  twitchings,  which,  like  it,  spring  from  a  deranged  inner- 
vation rather  than  from  organic  disease.  But  it  differs  from  these 
spasmodic  movements  by  being  more  incessant,  and  unconnected 
with  decided  muscular  contractions.  In  nervous,  susceptible  per- 
sons laboring  under  an  acute  attack  of  disease,  it  is  at  times 
combined  with  great  restlessness,  and  is  apt  to  be  mistaken  for 
a  convulsive  state.  Here  again  it  may  be  distinguished  by  the 
absence  of  muscular  contractions,  and  by  the  unintermitting  ir- 
regular motions. 

It  has  been  stated  above  that  tremor  is  the  chief  symptom  of 
paralysis  agitans.  Yet  this  is  not  necessarily  associated  with  per- 
sistent or  marked  organic  lesion  ;  the  trembling  is  combined  with 
muscular  weakness,  or  rather  with  slowness  of  muscular  action, 
and,  though  increased  by  exertion  and  me,ntal  excitement,  is  a  con- 
dition that  does  not  remit.  It  usually  follows  continuous  mental 
strain  or  some  depressing  acute  affection  in  elderly  persons,  comes 
<>n  -lowly  and  progresses  slowly.  As  it  advances,  the  patient  loses 
his  equilibrium  in  walking,  leans  forward  or  walks  on  the  fore 
part  of  the  foot,  and  is  rapidly  propelled  forward.  The  trembling 
takes  place  all  over  the  body  except  the  head.  It  is  in  more  or 
less  continuous  oscillations,  to  a  certain  extent  controlled  by  the 
will.  The  expression  of  the  countenance  is  altered  and  fixed; 
the  handwriting  is  tremulous.  Complaints  are  made  of  muscular 
stiffness,  especially  in  the  extremities,  and  of  a  sense  of  excessive 
heat,  but  there  are  no  cerebral  symptoms. 

Different  is  the  shaking  palsy,  which  is  dependent  upon  in- 
variable organic  lesion,  upon  disseminated  cerebrospinal  sclerosis, 
or  Charcot's  disease.     Now,  the  symptoms  of  this  vary  somewhat, 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  123 

as  the  nodules  of  hardened  tissue  affect  the  brain  or  the  cord  first. 
We  have  always  tremor  and  paralysis,  and  if  the  lesion  be  pri- 
marily in  the  brain  the  former  happens  first.  The  trembling  may 
show  itself  from  the  start  in  the  tongue  or  the  eyeball,  and  with 
it  we  usually  find  headache,  vertigo,  altered  sensibility,  amblyopia, 
impaired  hearing,  and  difficulty  in  enunciation.  The  want  of 
power  manifests  itself  in  all  the  extremities,  yet  the  lower  ex- 
hibit the  palsy  most  plainly  ;  unlike  paralysis  agitans,  the  paresis 
or  paralysis  often  precedes  the  tremor.  The  trembling  is  not 
witnessed  except  when  the  muscles  are  put  into  motion,  stops, 
therefore,  when  they  are  at  rest.  It  occurs  in  decided  jerks,  and 
markedly  affects  the  head,  when  this  is  moved  at  all.  The  gait 
is  uncertain,  tottering.  Sensation  is  not  affected,  nor  are  the 
sphincters.  Toward  the  end  muscular  cramps  followed  by  con- 
tractions, and  disorders  of  deglutition  and  respiration,  happen; 
it  is  in  very  advanced  cases  only  that  the  electro-muscular  contrac- 
tility or  the  galvanic  irritability  of  the  nerves  is  decidedly  dimin- 
ished. One  of  the  striking  features  of  disseminate  sclerosis  is  that 
there  are  at  times  long  delusive  periods  of  marked  improvement. 

Spasms — Convulsions. — Both  these  terms  are  applied  to 
involuntary  muscular  contractions,  with,  perhaps,  this  difference : 
the  word  spasm  is  used  when  we  wish  to  express  the  idea  of  less 
extensive  muscular  derangement,  but  especially  when  the  muscles 
of  organic  life  are  believed  to  be  involved ;  and  convulsions,  when 
the  disorder  affects  the  muscles  of  the  whole  body,  or  at  least  many 
muscles  at  once,  and  chiefly  those  of  volition.  Yet  these  are  not 
distinctions  that  can  be  very  strictly  carried  out,  for  the  two  phe- 
nomena often  coexist,  and,  being  produced  by  the  same  causes 
and  obedient  to  the  same  laws,  can  hardly  be  separated. 

Spasms  may  be  clonic  or  tonic.  In  clonic  spasms  the  muscles 
are  agitated  by  successive  contractions  and  relaxations  of  their 
fibres.  Clonic  spasms  are  very  extensive ;  in  truth,  so  generally 
is  this  the  case  that,  if  we  make  any  distinction  between  spasms 
and  convulsions,  we  are  bound  to  contemplate  clonic  spasms  as  con- 
vulsions rather  than  as  spasms.  In  tonic  spasms  the  muscles  are 
rigidly  set,  and  retain  for  a  time  their  contraction,  in  spite  of  every 
effort  on  our  part,  or  on  the  part  of  the  patient,  to  relax  them. 
The  most  marked  type  of  this  disorder  is  seen  in  tetanus;  the 
most  perfect  illustration  of  clonic  spasms  is  furnished  by  hysteria. 


124  MEDICAL    DIAGNOSIS. 

Convulsions  may  be  accompanied  by  a  loss  of  consciousness, 
and  abolished  sensibility,  as  in  epilepsy,  or  they  may  coexist 
with  unclouded  thought  and  unaltered  sensibility,  as  in  tetanus. 
What  their  immediate  cause  is,  it  is  very  difficult  to  determine; 
as  yet  we  possess  little  positive  knowledge ;  and  concerning  the 
portion  of  the  nervous  centres  where  they  arise,  or  the  struc- 
tural changes  that  attend  an  attack,  we  are  still  ignorant.  The 
seat  of  the  disturbance  is  in  some  cases  evidently  the  cerebro- 
spinal system ;  but  many  convulsions  have  their  origin  in  a  per- 
turbation of  the  reflex  system.  Of  their  exciting  cause  we  may 
say  that,  in  those  of  susceptible  nervous  organizations,  any  ex- 
trinsic irritation,  such  as  teething  or  disordered  digestion,  leads 
to  a  fit.  Further  causes  are  diseases  of  the  brain  ;  sudden  inter- 
ference with  the  circulation;  profuse  hemorrhages;  contaminated 
blood.  Children,  who  are  particularly  liable  to  convulsions,  often 
have  them  as  the  precursors  of  febrile  diseases.  In  point  of 
diagnosis  it  is  of  great  importance  to  distinguish  whether  their 
inroad  is  or  is  not  symptomatic  of  a  cerebral  lesion.  If  there 
have  been  a  previous  disorder  of  the  intellectual  functions,  or  any 
other  manifestation  of  a  brain  affection,  we  may  assume  the  con- 
vulsions to  be  the  signal  of  cerebral  mischief.  But  when  no  such 
phenomenon  is  met  with,  we  are  likely  to  find  the  source  of  irri- 
tation in  some  other  portion  of  the  body.  Practically  speaking, 
when  convulsions  are  among  the  first  signs  of  a  malady,  they  are 
apt  not  to  depend  upon  a  disease  of  the  brain;  and  even  if  recog- 
nized to  form  part  of  the  symptoms  of  a  cerebral  lesion,  we  may 
conclude  that  the  lesion  has  not  reached  its  highest  degree  of 
development,  but  is  still,  as  it  were,  irritative,  and  has  not  led  to 
cerebral  disorganization. 

Besides  separating  convulsions  or  spasms  in  conformity  with 
their  eccentric  or  their  centric  origin,  we  must  always  attempt  to 
ascertain  the  particular  nature  of  the  cause.  If  centric,  is  it  con- 
gestion, inflammation,  a  tumor,  induration  of  the  brain,  or  other 
lesion  ?  or  is  the  convulsion  essential  and  idiopathic,  and  due  to 
influences  the  cognizance  of  which  is  not  within  our  horizon  ?  If 
eccentric,  is  it  owing  to  an  impure  or  impoverished  blood,  to 
retained  poisons,  to  intestinal  or  other  visceral  irritation?  and  what 
is  the  probable  share  the  reflex  system  has  in  the  visible  dis- 
turbance of  the  muscles  ?     To  solve  these  questions  is  often  very 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  125 

difficult,  and  nothing  but  a  careful  analysis  of  all  the  phenomena 
of  the  case  enables  us  even  to  approximate  the  truth. 

Among  the  most  extraordinary  forms  of  spasm  connected  with 
increased  reflex  irritability  of  the  cord  is  the  so-called  saltatory 
spasm,  in  which  so  violent  a  spasm  of  the  legs  takes  place  when 
the  patient's  feet  touch  the  floor  that  he  is  thrown  into  the  air. 
Other  forms  of  tonic  or  clonic  spasm  happen  in  different  parts 
of  the  body  from  reflex  irritation  of  certain  nerve-tracts,  and  these 
spasms  produce  for  the  time  being  the  most  singular  contortions 
and  deformities.  We  find  them  limited  to  the  legs,  or  to  one  leg, 
to  the  arms,  to  the  muscles  of  respiration,  and  tonic  contractions 
are  very  apt  to  alternate  with  clonic  spasms ;  or  there  may  be  only 
complete  tonic  spasm  during  attempts  at  moving  certain  muscles. 
This  kind  of  spasm  is  sometimes  hereditary. 

Closely  connected  with  spasms  and  convulsions,  and  indeed,  in 
a  certain  sense,  not  separable  from  them,  are  other  kinds  of  irreg- 
ular muscular  movements,  such  as  cramps, — a  contraction  of  short 
duration  of  one  or  several  muscles,  occurring  in  paroxysms  and 
attended  with  severe  pain ;  rigidity, — a  permanent  tonic  contrac- 
tion of  the  muscles,  often  encountered  in  diseases  of  the  brain; 
and  the  jerking  movements  of  chorea.  Now,  some  of  these,  espe- 
cially localized  spasm  and  even  rigidity,  have  a  strong  connection 
with  the  seat  and  character  of  the  lesion.  Thus,  broadly  speak- 
ing, if  we  have  spasm,  perhaps  alternating  with  chorea-like  move- 
ments, confined  to  one  arm,  one  leg,  one  group  of  muscles,  we  may 
infer  an  irritative  lesion  in  the  cortical  motor  area,  one  which  is 
most  likely  associated  with  an  effort  at  cicatrization  after  an  injury 
to  the  brain-substance  of  these  parts.  But  the  same  symptoms 
may  also  precede  the  breaking  down  of  the  gray  cortical  matter; 
and  in  either  case  one-sided  paresis  or  paralysis  is  likely  to  attend 
the  morbid  phenomena. 

DERANGED   NUTRITION   AND   SECRETION. 

Among  the  subjects  connected  with  the  nervous  system  which 
have  of  late  years  received  most  attention,  there  is  none  of  more 
interest  than  the  association  of  its  disorders  with  derangements 
of  nutrition  and  secretion.  Now,  such  are  manifest  in  paralyzed 
limbs  or  after  nerve-wounds.  But  these  obvious  alterations  need 
here  only  be  referred  to.     It  is  rather  my  intention  to  speak  of  the 


126  MEDICAL    DIAGNOSIS. 

less  palpable  phenomena,  and  those  in  which,  at  first  sight,  the 
nervous  system  is  not  so  distinctly  concerned.  For  instance,  the 
skin  may  become  the  seat  of  diverse  eruptions,  undergo  modifica- 
tions of  color  and  structure,  the  secretions  may  be  augmented  or 
diminished,  the  muscles  and  joints  show  textural  changes,  swell- 
ings may  happen  affecting  various  portions  of  the  body,  either 
external  or  internal, — yet  all  be  due  to  disturbed  nervous  influ- 
ence, and  the  real  disorder,  therefore,  be  in  parts  very  different 
from  where  it  appears. 

To  particularize  with  reference  to  a  few  of  the  derangements 
alluded  to.  There  is  the  affection  known  as  herpes  zoster,  in 
which  the  vesicles  encircling  half  the  circumference  of  the  trunk 
are  not  a  primary  skin  affection,  but  the  local  expression  of  irri- 
tation of  a  nerve.  They  closely  follow  the  distribution  of  some 
superficial  sensory  nerve,  and  this  unilateral  herpes  is  really  but 
a  sign  of  localized  neuralgia, — most  generally  of  a  dorso-inter- 
costal  neuralgia.  Then  again  we  encounter  instances  of  large 
vesicles  or  bullae  accompanying  other  neuralgias,  as  of  the  sciatic; 
and  attacks  of  erysipelas  having  their  origin  in  facial  neuralgia, 
as  has  been  demonstrated  by  Anstie.  Furthermore,  various  kinds 
of  spots  and  blotches,  and  thickenings  of  the  skin,  have  been 
noticed  after  this  and  other  forms  of  neuralgia.  Then,  too,  we 
may  have  eczema  of  nervous  origin  produced  by  reflex  irritation 
in  instances  of  disorders  of  the  urinary  organs.* 

Oftentimes,  too,  these  morbid  appearances  on  the  skin  are  com- 
bined with  evidences  of  altered  secretion.  Thus,  in  a  case  related 
by  Parrot,!  in  addition  to  the  neuralgic  paroxysms  attended  with 
sanguineous  exudations  at  the  painful  parts,  there  occurred,  at 
times,  bloody  sweating  of  the  knees,  thighs,  hands,  and  face. 
Lachrymation  was  noticed  in  nearly  half  the  cases  of  trigeminal 
neuralgia  analyzed  by  Xotta  ;t  and  one-sided  furring  of  the  tongue 
is  a  not  uncommon  phenomenon  in  this  complaint.  Associated 
with  these  evidences  of  altered  secretion  mav  be  siffns  of  altered 
nutrition,  such  as  iritis,  corneal  clouding,  and  inflammation  of 
the  fascia  or  of  the  periosteum  in  contact  with  the  aching  nerve. 

*  Ord,  St.  Thomas's  Hospital  Reports,  vol.  vii.,  1876. 

f  Gaz.  Hebdom..  1859;  quoted  in  Handfield  Jones  on  Functional  Nervous 
Disorders. 

%  Archives  Generales  de  Medecine,  1854. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  127 

Let  us  here  add  that  these  manifestations  of  perverted  nutrition 
are  not  confined  to  neuralgic  disorders.  They  occur  also  in  dis- 
eases of  the  central  nervous  system.  Thus,  affections  of  the  joints 
have  been  observed  to  follow  cerebral  hemorrhages,  and  various 
spinal  disorders ;  and  a  form  of  joint-mischief,  of  hydrarthrosis, 
has  been  specially  described  in  locomotor  ataxia  by  Charcot.* 

Among  the  phenomena  of  altered  secretion,  connected  with 
nervous  affections,  one  of  the  most  striking  is  excessive  sweating. 
In  lesions  of  the  cervical  sympathetic  on  one  side,  we  may  have 
strictly  unilateral  sweating  of  the  face  and  neck,  the  other  side 
remaining  perfectly  dry  ;f  and  greater  vascularity  and  increased 
temperature  are  concomitants.  In  lesions  of  the  abdominal  gan- 
glia, profuse  sweating  also  happens,  and  is  apt  to  be  combined  with 
impeded  secretion  from  the  mucous  coats  of  the  bowels,  as  we 
at  times  find  in  instances  of  abdominal  aneurism.  Not  that  ex- 
cessive sweating,  whether  localized  or  general,  is  always  linked 
to  an  affection  of  the  great  sympathetic  ganglia.  AVe  find  local 
sweatings  limited  to  the  hands  and  feet  without  any  signs  of 
other  disorder.  And  general  sweatings,  irrespective  of  those  of 
colliquative  character  attending  phthisis,  or  of  those  of  malarial 
diseases,  happen  after  low  fevers,  in  inactive  states  of  the  liver, 
and  in  some  persons  go  on  for  years  without  obvious  cause.  It 
may  be  that  in  most  if  not  in  all  of  these  cases  the  sympathetic 
system  is  really  at  fault,  at  least  in  so  far  that  there  is  a  reflex 
derangement  of  the  vaso-motor  nerves,  and  of  course,  then,  of 
the  subcutaneous  blood-vessels  and  of   the  glands  they  supply. 

But  these  are  not  questions  which  we  can  here  consider.  In- 
deed, the  why  and  the  how  of  all  these  changes  of  secretion  and 
nutrition  attending  nervous  affections  are  very  uncertain,  and  such 
a  consideration  touches  on  the  question  whether  or  not  there  are 
special  trophic  nerves,  and  on  other  unsettled  points  in  physiology. 

To  return  to  the  clinical  phenomena.  Besides  the  external 
manifestations  of  altered  secretion  and  nutrition,  there  are  certain 
changes  in  internal  organs,  the  expression  of  nervous  derange- 
ment. Modern  research  has  rendered  it  most  probable  that  the 
triple  lesion  known  as  exophthalmic  goitre  is  of  this  kind,  and 
due  to  disease  of  the  sympathetic  nerve.     And  the  Medicine  of 

*  Archives  de  Physiologie,  1868. 

f  As  in  the  case  recorded  by  W.  Ogle,  Med.-Chir.  Transact.,  vol.  lii. 


128 


MEDICAL   DIAGNOSIS. 


the  Future  will  most  likely  acquaint  us  with  many  more  disorders 
of  glands  and  viscera  which  originate  in  altered  nerve-structure 
and  in  perverted  power. 

So  much  for  the  chief  manifestations  of  nervous  complaints. 
From  the  preceding  pages  it  will  have  become  apparent  how  many 
of  them  are  functional,  or  are  at  least  of  necessity  so  regarded, 
and  how  these  functional  disorders  may  be  attended  with  the  signs 
of  as  great  disturbance  as  the  organic  maladies.  And  nothing 
is  more  difficult  than  to  fix  their  seat;  for  after  death  not  the 
slightest  structural  alteration  may  be  discernible,  or  it  may  be  of 
a  character  insufficient  to  account  for  the  phenomena  during  life. 
In  consequence,  there  is  confusion,  and  doubt  is  thrown  over  any 
anatomical  or  pathological  classification  of  nervous  diseases.  I 
subjoin  a  table  of  the  main  affections,  arranged  according  to  their 
supposed  sites.  It  may  not  suit  a  strict  critic,  since,  in  several  of 
the  disorders  regarded  as  functional,  modern  research  has  indicated 
the  probable  organic  cause.  But  from  the  point  of  view  of  the 
physician  it  would  be  premature  to  recognize  a  fixed  organic 
nature,  and  I  contend  rather  for  the  classification  being  useful 
clinically  than  unimpeachable  pathologically.  Nor  will  it  be  ad- 
hered to  in  the  description  of  nervous  affections  about  to  follow ; 
which  will  be  traced  according  to  divisions  formed  by  groups  of 
symptoms  rather  than  in  obedience  to  a  pathological  classification. 


Organic. 


TABLE    OF    THE   AFFECTIONS    OF   THE    BRAIN   AND    SPINAL    CORD. 

C  f  Hyperemia. 

Anaemia. 

Meningitis  in  its  various  forms. 
Hydrocephalus. 
Abscess. 
Softening. 
Sclerosis. 
Hemorrhage  (Apoplexy). 

CEREBRAL -,  Thrombosis. 

Embolism. 
Tumors,  etc. 
Syphilitic  affections. 
Delirium. 
Insanity  ? 
Functional.  -,   Hypochondriasis. 
Headache. 
Trance. 


DISEASES   OF   THE   BRAIX  AND   SPIXAL   COED. 


129 


Cerebro-spinal  meningitis. 
Organic \   Cerebro-spinal  sclerosis. 


I 


Spistal. 


Organic. 


Functional. 


I  Hydrophobia. 
'  Epilepsy. 

Catalepsy. 
Functional.  -|   Ecstasy. 

Chorea. 
L  l_  Hysteria? 

f"  Hyperemia. 

Anaemia. 

Spinal  meningitis. 

Myelitis  in  various  forms. 

Softening. 

Atrophy. 

Sclerosis. 

Locomotor  ataxia. 

Spinal  apoplexy. 

Tumors,  etc. 

Syphilitic  affections. 
[  Wasting  palsy  ? 
f  Spinal  irritation. 

Spinal  exhaustion. 

Tremor. 
j   Paralysis  agitans. 
|   Tetanus. 
I  Keflex  spasms  due  to  irritation  of  the  cord. 

Acute  Affections  of  which  Delirium  is  a  Prominent  Symptom, 
This  clinical  group  embraces  the  different  forms  of  meningeal 
inflammation,  delirium  tremens,  and  acute  mania, — affections  in 
all  of  which  the  brain  is  the  seat  of  the  disturbance. 

Acute  Meningitis. — By  this  term  is  now  understood  an  in- 
flammation of  the  membranes  of  the  brain,  especially  of  the  arach- 
noid and  of  the  pia  mater.  The  dura  mater  is  far  less  frequently 
attacked ;  very  rarely,  unless  the  morbid  action  be  of  syphilitic 
origin,  or  have  extended  from  the  bones  of  the  cranium,  or  have 
resulted'from  an  injury. 

The  disease  generally  presents  two  well-marked  stages.  The 
first,  or  the  stage  of  excitement,  is  characterized  by  intense  head- 
ache, great  restlessness,  vomiting,  a  hard,  frequent  pulse,  fever, 
injected  eye,  often  with  a  contracted  pupil,  an  increased  sensibility 
to  light  and  sounds,  obstinate  constipation,  irregular  respiration, 
and  soon  by  active  delirium, and  by  convulsions;  the  second  stage 
is  marked  by  an  evident  ebbing  of  the  life-forces  :  the  extremities 


130  MEDICAL    DIAGNOSIS. 

are  cold,  the  pupils  dilated,  the  pulse  is  feeble  and  much  slower, 
and  intermitting,  or  it  becomes  extremely  rapid  and  threadlike; 
involuntary  passages  occur;  there  is  utter  loss  of  mind  and  of 
sensibility, — in  one  word,  coma  or  collapse. 

Not  every  case,  however,  has  all  these  symptoms,  or  goes  at 
once  from  the  stage  of  excitement  to  that  of  collapse.  There  may 
be  a  well-defined  period  of  transition,  during  which  the  heat  of 
skin,  except  of  the  head,  diminishes,  drowsiness  appears,  and  the 
pulse  sinks  somewhat  in  frequency.  Again,  the  disease  may  be 
arrested  before  the  signs  of  prostration  are  very  evident. 

The  attack  may  be  preceded  by  sick  stomach,  buzzing  in  the 
ears,  and  vertigo,  or  it  may  set  in  with  severe  pain  fixed  to  the 
forehead  and  increased  by  movement.  In  some  cases  it  begins 
with  delirium  or  convulsions.  On  the  other  hand,  these  signs 
may  be  absent.*  Among  its  symptoms,  even  in  the  earliest 
stages,  a  persistent  pain,  attacking  one  or  both  knees,  violent, 
intensified  on  motion,  unrelieved  by  local  means,  and  connected 
neither  with  swelling  nor  with  any  other  change  in  the  form  or 
appearance  of  the  joint,  has  been  particularly  noticed. f 

The  malady  may  pass  rapidly  through  its  stages,  so  rapidly  that 
their  distinctive  features  become  confused  and  blended.  Generally 
it  does  not  last  less,  or  much  more,  than  a  week. 

Acute  meningitis  is  brought  on  by  exposure,  by  depressing  cares, 
by  intense  application  to  study,  by  a  blow  or  fall  upon  the  head, 
by  disease  of  adjacent  structures,  or  by  syphilis.  It  sometimes 
affects  mainly,  or  wholly,  the  coverings  of  the  convex  portion  of 
the  brain  ;  at  other  times  the  inflammation  is  limited  to  the  base. 
Meningitis  of  the  convexity  is  very  apt  to  be  purulent.  It  gen- 
erally comes  on  suddenly,  and  is  found  to  be  connected  with  dis- 
ease of  the  bones  of  the  skull,  with  disease  of  the  ear,  or  it  follows 
exposure  to  the  rays  of  the  sun.  Severe  headache,  hyperesthesia, 
rigidity  of  the  neck,  spasms  in  the  facial  muscles  of  one  side  and  in 
one  or  both  arms,  are  among  the  most  marked  symptoms. 

According  to  Duchatelet,|  meningitis  of  the  base  may  be  dis- 
criminated by  remissions  in  the  delirium,  and  by  the  coexistence 

*  In  a  paper  by  Church,  in  St.  Bartholomew's  Hospital  Reports,  vol.  iv., 
several  cases  without  delirium  are  narrated. 

f  Lund,  quoted  in  Amer.  Journ.  of  Med.  Sciences,  Oct.  1864. 
X  Inflammation  de  l'Arachnoide,  p.  230. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  131 

of  spasmodic  symptoms  with  profound  and  early  coma.  These 
signs,  at  all  events,  are  said  to  be  distinctive  in  children,  who, 
more  than  adults,  are  disposed  to  this  form  of  the  complaint.  In 
some  cases  acute  muscular  pains  with  defective  motor  power,  a 
clear  mind  until  late  in  the  disorder,  a  temperature  of  105°,  much 
higher  than  is  reached  in  cerebro-spinal  meningitis,  have  been 
specially  noticed.*  Moreover,  the  long  duration  of  the  malady, — 
for  it  lasts  for  weeks, — with  the  delirium  of  varying  intensity,  the 
intervals  of  clearness,  and  the  late  and  incomplete  palsies,  is  re- 
garded as  very  significant  of  this  simple  basilar  meningitis.f  The 
recognition  with  any  certainty  of  the  membrane  chiefly  involved 
is  not  possible.  Inflammation  of  the  dura  mater  has  the  least 
severe  and  striking  symptoms. 

Acute  meningitis  is  not  always  easy  of  diagnosis.  Leaving  out 
for  the  present  the  other  disorders  belonging  to  the  same  group, 
such  as  acute  mania  and  delirium  tremens,  it  may  be  confounded 
with 

Cerebritis  ; 

Acute  Softening; 

Head  Symptoms  of  Continued  Fevers  ; 

Head  Symptoms  of  Acute  Rheumatism; 

Head  Symptoms  of  Pneumonia;   of  Pericarditis. 

Cerebritis. — There  is  little  appreciable  difference  between  in- 
flammation of  the  brain-tissue  and  inflammation  of  the  meninges. 
In  truth,  what  we  commonly  call  meningitis  (because  the  evi- 
dences of  the  morbid  action  are  most  distinct  in  the  meninges)  is 
not  unfrequently  also  cerebritis;  since  the  diseased  process  extends 
readily  from  the  tunics  of  the  brain  to  the  adjacent  cerebral  sub- 
stance. We  may  suspect  this  structure  to  have  become  involved, 
if  the  sense  of  vision  or  of  hearing  be  suddenly  perverted ;  if  the 
convulsions,  the  agitation  of  the  limbs,  and  the  tremors  be  very 
marked ;  if  they  occur  chiefly  upon  one  side ;  and  if  coma  suc- 
ceed rapidly  to  the  period  of  excitement,  and  be  accompanied  or 
preceded  by  one-sided  palsy. 

Acute  Softening. — The  form  of  acute,  softening  which  simulates 
meningitis  is  that  associated  with  delirium.     But  it  occurs  only 


*  Dowse,  Medical  Times  and  Gazette,  Feb.  1874. 
f  Huguenin,  in  Ziemssen's  Cyclopeedia. 


132  MEDICAL    DIAGNOSIS. 

in  very  old  persons,  is  apt  to  be  preceded  by  restlessness,  some 
mental  confusion,  and  signs  of  a  general  breaking  up  of  nerve- 
force,  is  soon  associated  with  disturbances  of  the  bladder  and 
rectum,  and  the  patient  gradually  passes  into  a  comatose  state. 
In  the  cases  which  I  have  seen  there  was  neither  much  headache 
nor  febrile  disorder. 

Head  Symptoms  of  Continued  Fevers. — In  all  the  varieties  of 
continued  fever,  but  especially  in  typhoid  and  typhus,  cerebral 
symptoms  at  times  arise  which  bear  a  strong  resemblance  to  those 
of  idiopathic  meningitis ;  and  such  symptoms  may  appear  with- 
out the  examination  of  the  dead  body  revealing  even  traces  of 
inflammation.  How,  then,  are  we  to  distinguish  these  fever  cases 
from  meningitis?  or  how  ascertain  if  inflammation  of  the  brain 
be  really  before  us  as  a  complication  and  product,  if  thus  it  may 
be  called,  of  the  fever?  Unfortunately,  there  is  no  sign  abso-  ' 
lutely  diagnostic.  The  increase  of  phosphates  in  the  urine,  found 
by  Bence  Jones  to  occur  in  inflammatory  affections  of  the  nervous 
textures,  is  thought  to  furnish  a  valuable  source  of  distinction. 
But  we  know  that  this  increase  may  also  be  due  to  other  causes, 
and  as  yet  we  are  too  little  cognizant  of  the  exact  chemistry  of  the 
secretions  in  the  maladies  under  discussion  to  make  the  urine  the 
differential  test.  Xor  does  cerebral  auscultation  afford  us  any 
help;  for  the  few  authors,  such  as  Fisher,*  Whitney,!  Roger,;}; 
Jurasz,§  who  have  at  all  investigated  the  subject,  are  not  even 
agreed  whether  the  blowing  sound  that  is  perceived  is  constantly 
present  in  meningitis,  whether  it  may  not  exist  in  any  cerebral 
disturbance,  nay,  whether  it  may  not  be  heard  in  health.  As 
matters  stand,  a  diagnosis  can  be  established  only  by  a  careful 
consideration  of  all  the  symptoms,  and  of  the  history  of  our 
patient:  by  searching  for  the  eruption  of  typhus  or  typhoid 
fever ;  by  taking  note  of  the  expression  of  the  countenance ;  of 
the  character  of  the  delirium,  ordinarily  so  much  more  active 
when  the  brain  or  its  membranes  are  inflamed,  and  attended  with 
much  more  intense  headache,  with  throbbing  of  the  arteries  of  the 
neck  and  face, — a  symptom,  however,  not  conclusive,  for  I  have 

*  Amer.  Journ.  of  Med.  Sciences,  Aug.  1838. 

f  Ibid.,  Oct.  1843. 

+  Ibid.,  Oct.  1- 

l  Schmidt's  Jahrbucher.  No.  7,  1878. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  133 

repeatedly  noticed  it  in  low  fevers, — and  not  unfrequent.lv  with 
convulsions.  But  how  difficult  it  may  be  to  arrive  at  a  correct 
conclusion,  unless  we  possess  a  full  knowledge  of  all  the  circum- 
stances, is  shown  by  this  case  : 

A  man,  about  thirty-five  years  of  age,  was  admitted  into  the 
Philadelphia  Hospital  on  February  8th,  1861,  with  a  certificate 
that  he  was  laboring  under  typhoid  fever.  No  clue  could  be  ob- 
tained to  the  history  of  the  malady.  The  man  himself  was  not  in 
a  state  to  answer  any  questions.  His  pulse  was  excessively  feeble, 
and  somewhat  irregular;  the  eye  was  not  injected,  but  suffused 
and  watery ;  the  pupils  were  sluggish  and  the  eyeballs  in  constant 
motion  ;  the  tongue  was  dark,  dry,  and  fissured ;  the  breath  offen- 
sive. There  appeared  to  be  pain  on  pressure  in  the  right  iliac 
fossa,  but  the  bowels  were  constipated,  and  no  eruption  could  be 
detected.  The  most  striking  feature  of  the  case  was  the  delirium, 
which  was  noisy  and  violent  and  accompanied  by  great  restless- 
ness ;  the  man  sang,  screamed,  was  constantly  attempting  to  get 
out  of  bed  and  to  upset  his  medicine-bottle.  What  was  the  nature 
of  the  malady  ?  It  did  not  seem  to  me  to  be  typhoid  fever ;  the 
symptoms  belonged  more  to  inflammation  of  the  brain,  but,  know- 
ing neither  how  nor  when  the  delirium  had  commenced,  I  could 
not  be  positive  that  such  was  the  lesion.  The  bowels  were  opened 
by  a  turpentine  injection,  and,  as  the  patient  was  evidently  sinking, 
he  was  stimulated ;  but  to  no  purpose :  he  died  the  day  after  his 
admission  into  the  hospital.  The  autopsy  showed  the  intestines  to 
be  sound.  The  membranes  of  the  brain,  after  the  dura  mater  was 
removed,  were  found  to  be  opaque,  and  between  the  convolutions 
were  shreds  of  lymph  and  a  puriform  liquid.  There  were  only 
traces  of  inflammation  at  the  base,  except  in  the  neighborhood  of 
the  pons  Varolii,  where  some  lymphy  effusion  was  discerned.  The 
ventricles  were  filled  with  fluid,  and  the  nervous  structure  in  the 
neighborhood  of  the  thalami  and  corpora  striata  was  softened. 

Subsequently  to  the  man's  death  it  was  ascertained  that  he  had 
been  sick  for  only  four  days  before  he  entered  the  ward ;  which 
fact,  had  it  been  previously  known,  would  have  materially  assisted 
the  diagnosis.  Irrespective  of  the  difficulty  of  its  recognition, 
this  case  is  of  peculiar  interest.  It  illustrates  the  possibility  of 
the  absence  of  convulsions  and  of  paralysis,  notwithstanding  the 
most  evident  cerebral  disorganization. 


134  MEDICAL    DIAGNOSIS. 

Head  Symptoms  of  Acute  Rheumatism. — In  rheumatic  fever 
cerebral  symptoms  occasionally  arise  which  may  be  referred  to 
inflammation  of  the  brain,  or  which,  by  their  prominence,  may 
mislead  the  practitioner,  causing  him  to  regard  the  signs  of  the 
rheumatism  as  of  little  importance,  if  indeed  he  do  not  wholly 
overlook  them.  The  morbid  manifestations  are  very  much  like 
those  of  acute  meningitis :  restlessness,  headache,  and  violent  de- 
lirium, succeeded  by  coma.  The  delirium  is  commonly  of  gradual 
approach,  but  it  may  come  on  suddenly.  Generally  it  does  not 
appear  until  the  patient  has  been  suffering  for  at  least  a  week  with 
acute  rheumatism  ;  and  the  heavy  sweats  and  swollen  joints  point 
out  the  malady  with  which  it  is  combined. 

Formerly  the  cerebral  phenomena  were  looked  upon  as  due  to 
metastasis  of  the  rheumatic  inflammation  to  the  brain.  But  this 
view  is  not  tenable;  for  examinations  of  the  head,  in  cases  which 
had  proved  rapidly  fatal,  have  failed  to  detect,  save  in  rare  in- 
stances, any  evidences  of  inflammatory  action  within  the  cranium. 
The  abnormal  signs  are,  as  a  rule,  more  properly  attributable  to 
the  rheumatic  poison  seizing  upon  the  brain,  and  to  the  altered 
condition  of  the  blood.  They  are  at  times  found  to  be  connected 
with  the  setting  in  of  inflammation  of  the  membranes  of  the  heart, 
or  of  pneumonia,  or  with  albuminuria,  or  with  plugs  of  fibrin  in 
the  capillaries  of  the  brain,  and  are  not  unfrequently  associated 
with  a  very  high  temperature.* 

Head  Symjitoms  of  Pneumonia;  of  Pericarditis. — In  both  these 
maladies  delirium  may  be  met  with  of  a  character  so  violent  as  to 
lead  to  the  belief  that  the  brain  or  its  membranes  are  involved  in 
an  inflammatory  disease.  The  diagnosis  is  cleared  up  by  a  careful 
examination  of  the  chest.  Then  we  may  lay  stress  on  the  furious 
delirium  being  unattended  with  spasmodic  movements  or  with 
paralysis.  The  form  of  pneumonia  which  is  mostly  associated 
with  delirium  is  inflammation  of  the  upper  lobes. 

Tubercular  Meningitis. — This  is  a  rare  disease  in  adults; 
not  a  rare  disease  in  children.  Its  distinct  recognition  belongs  to 
the  present  generation  of  physicians ;  and  nearly  all  of  the  cases 


*  For  a  collection  of  cases  and  fuller  particulars,  I  may  refer  to  a  paper  on 
Cerebral  Rheumatism  which  I  published  in  the  American  Journal  of  the 
Medical  Sciences,  Jan.  187-Y 


DISEASES    OE    THE    BRAIN    AND    SPINAL    CORD.  135 

of  so-called  acute  hydrocephalus,  and  most  of  those  of  meningitis 
of  the  base,  have  now  been  ascertained  to  be  instances  of  tuber- 
cular meningitis,  or,  to  define  the  morbid  state,  of  an  inflamma- 
tion of  the  meninges  occurring  in  tubercular  patients,  and  ordi- 
narily accompanied  by  the  deposition  of  tubercles  at  the  base  of 
the  brain. 

The  premonitory  signs  of  the  malady  are  of  great  importance. 
The  child  has  generally  been  ailing  for  some  time;  is  restless, 
peevish,  sleeps  badly,  complains  of  headache,  and  is  troubled  with 
a  frequent,  short  cough,  and  with  constipation.  To  these  symp- 
toms are  soon  superadded  thirst,  a  slightly  coated  tongue,  vomit- 
ing, a  dry  skin,  and  generally  an  accelerated  pulse  and  grinding 
of  the  teeth,  constituting  the  most  prominent  features  of  the  first 
stage  of  the  affection.  After  four  or  five  days  the  second  stage  is 
reached,  and  the  brain  symptoms  become  more  clearly  developed. 
The  child  shuns  the  light,  puts  the  hand  frequently  to  its  head, 
and  utters  now  and  then  a  peculiar,  sharp,  distressing  cry.  At 
night  the  headache  exacerbates,  and  is  attended  with  fleeting  de- 
lirium. A  slight  strabismus  is  observable,  and  the  eyeballs  oscil- 
late. The  pulse  is  very  irregular  in  its  rhythm,  sometimes  rapid 
and  intermitting,  then  suddenly  falling  and  becoming  quite  slow. 
The  vomiting  ceases,  and  there  may  be  a  remission  in  the  symp- 
toms, with  restored  intelligence ;  but  the  pulse  remains  irregular, 
the  bowels  are  even  more  constipated  than  before,  and  the  ab- 
domen appears  retracted.  The  third  stage  is  one  of  complete 
stupor,  accompanied  or  preceded  by  convulsions.  The  expression 
of  the  face  is  idiotic ;  the  pupils  are  dilated ;  there  is  subsultus, 
and  one  side  of  the  body  is  paralyzed.  Deglutition  is  difficult; 
the  surface  is  covered  with  cold  sweats.  This  condition,  so  pain- 
ful to  behold,  may  last  for  days ;  repeated  convulsions  hasten  its 
termination. 

Can  we  distinguish  this  formidable  complaint  from  ordinary 
meningitis?  Seldom  from  meningitis  of  the  base;  generally  from 
meningitis  of  the  convexities.  As  regards  the  discrimination  from 
the  former  malady,  we  are,  it  is  true,  sometimes  enabled  to  pro- 
nounce the  affection  to  be  tubercular  meningitis,  if  we  are  familiar 
with  the  patient's  antecedents,  and  are  cognizant,  previous  to  the 
seizure,  of  the  presence  of  tubercle  in  any  of  the  internal  organs, 
or  are  able  at  the  time  to  detect  the  signs  of  tubercular  phthisis. 


136  MEDICAL    DIAGNOSIS. 

But  without  knowledge  of  this  kind,  a  positive  diagnosis  is  im- 
possible: we  have,  notwithstanding  some  of  the  symptoms  above 
mentioned  in  discussing  basilar  meningitis,  nothing  to  direct  us 
except  the  probability  that  the  case  is  tubercular,  because  most  in- 
stances of  meningitis  of  the  base  are  of  that  nature.  This  uncer- 
tainty  does  not  exist  with  reference  to  the  usual  form  of  simple 
meningeal  inflammation.  We  may  generally  distinguish  the  tuber- 
cular malady  by  its  occurrence  in  an  unhealthy  person  ;  by  its  in- 
sidious approach ;  by  the  absence  of  violent  delirium;  by  the  ap- 
pearance of  convulsions,  not  early,  but  late  in  the  disease ;  by  the 
far  less  violent  headache,  and  less  degree  of  febrile  excitement ;  by 
the  notable  remissions  in  several  of  the  cerebral  signs ;  by  the 
chest  symptoms,  and  the  long  duration  of  the  affection. 

Tubercular  meningitis  is  ordinarily  attended  with  an  effusion  of 
serum  into  the  ventricles,  and  it  is  plain  that  many  of  the  symp- 
toms are  attributable  to  pressure  of  the  fluid  on  portions  of  the 
brain.  Xow,  how  can  we  separate  the  malady,  acute  hydroceph- 
alus, as  many  still  call  it,  from  dropsy  of  the  brain,  or  chronic 
hydrocephalus  f  Partly  by  the  history  of  the  case,  and  partly  by 
the  normal  size  of  the  head ;  for  the  water  on  the  brain  is  not 
sufficient  in  amount,  nor  is  it  there  long  enough,  to  produce  an 
appreciable  augmentation  of  the  cranium.  Then,  in  chronic 
hydrocephalus  the  symptoms  manifest  themselves  for  years,  from 
childhood  even  to  adult  life.  The  signs  of  a  profound  cerebral 
lesion  appear  gradually,  the  special  senses  are  by  degrees  enfeebled, 
but  it  is  a  long  time  before  they  are  wholly  abolished,  or  before 
complete  loss  of  consciousness  takes  place. 

As  regards  the  diagnosis  between  tubercular  meningitis  and 
acute  hydrocephalus,  it  need  only  be  stated  that  the  latter  affection 
is  in  the  vast  majority  of  cases  a  synonym  for  the  former.  Yet 
we  occasionally  meet  with  instances  in  which  acute  hydrocephalus 
occurs  unconnected  with  tubercle.  It  then  runs  either  a  latent 
course,  or  appears  as  an  acute  malady  with  symptoms  similar  to 
those  of  acute  meningitis,  commencing  either  with  fever  or  with 
convulsions,  and  often  attended  with  intense  restlessness,  succeeded 
by  drowsiness,  and  having  periods  of  intermission  of  the  symp- 
toms and  of  apparent  improvement.  Toward  the  end  convul- 
sions are  common.  The  complaint,  unlike  tubercular  meningitis, 
happens  in  previously  healthy  children,  begins  suddenly,  and  is 


DISEASES    OF    THE    BEAIX    AND    SPINAL    CORD.  137 

of  short  duration.  But  the  effusion  may  remain,  and  the  disorder 
lead  to  chronic  hydrocephalus. 

There  is  a  functional  disturbance  of  the  brain  of  great  impor- 
tance to  discriminate  from  tubercular  meningitis, — the  hydroceph- 
aloid  disease  described  by  Marshall  Hall.  It  has  a  stage  of  irri- 
tability, and  a  stage  of  torpor:  a  stage  in  which  the  little  patient 
is  restless,  feverish ;  and  a  stage  in  which  the  countenance  becomes 
pale,  the  breathing  irregular,  the  voice  husky,  and  the  pupils  are 
uninfluenced  by  light.  These  symptoms  indicate  nervous  ex- 
haustion. They  generally  come  on  after  an  enfeebling  attack  of 
illness,  especially  subsequent  to  protracted  diarrhoea;  sometimes 
they  follow  premature  weaning.  In  the  history  of  the  case ;  in 
the  less  tendency  to  vomiting;  in  the  regularity  of  the  pulse;  in 
the  flaccid  and  hollow  state  of  the  fontanelle,  so  dissimilar  to  its 
prominent  and  tense  condition  in  inflammation ;  and  in  the  arrest 
of  the  threatening  signs  by  stimulants  and  by  tonics,  we  find  the 
guides  which  enable  us  to  decide  against  the  existence  of  an  organic 
disease  of  the  brain  or  its  membranes. 

But  other  affections  besides  those  of  the  brain  may  be  con- 
founded with  tubercular  meningitis,  such  as  typhoid  and  remittent 
fevers.  From  typhoid  fever  tubercular  meningitis  may  be  dis- 
tinguished by  the  frequent  vomiting ;  by  the  retracted  abdomen, 
so  unlike  the  swollen,  tender  belly  of  enteric  fever ;  by  the  con- 
stipation instead  of  the  diarrhoea;  by  the  normal  size  of  the 
spleen ;  by  the  irregularity  of  the  pulse ;  by  the  occurrence  of 
convulsions  and  anaesthesia,  and  other  signs  of  profound  motor 
and  sensorial  disturbance,  and  by  the  lower  heat,  the  thermometer 
seldom  rising  above  102°.  I  have  never  seen  an  eruption  in 
tubercular  meningitis ;  but  Barthez  and  Billiet  speak  of  fugitive 
imperfectly-formed  rose-spots  being  present  in  rare  cases.  The 
duration  of  the  two  complaints  affords  no  help  in  diagnosis,  since 
the  one  may  last  as  long  as  the  other. 

Tubercular  meningitis  is  often  mistaken  for  infantile  remittent 
fever  ;  indeed,  there  are  many  points  of  close  resemblance  between 
them.  Without  mooting  the  question  whether  the  remittent  fever 
of  children  be  really  a  distinct  disease,  we  may  here  accept  the 
group  of  clinical  phenomena  supposed  to  be  characteristic,  and 
point  out  the  differences  between  them  and  those  of  tubercular 
or  scrofulous  inflammation  of  the  brain.     In  the  first  place,  ex- 


138  MEDICAL    DIAGNOSIS. 

cept  in  those  rare  cases  of  coexisting  acute  tuberculization  of  the 
intestines,  we  do  not  perceive  in  the  cerebral  disorder  a  tongue 
red  at  the  edges,  diarrhcea,  and  other  manifestations  of  intestinal 
irritation;  and  vomiting  and  nausea  are  more  prominent  and 
protracted  symptoms  than  in  the  febrile  malady.  But  in  this 
complaint  the  heat  of  skin  is  much  greater;  the  pulse  quicker, 
yet  not  unequal  and  subject  to  such  decided  variations;  delirium 
occurs  much  earlier,  and  is  much  more  marked, — indeed,  tuber- 
cular meningitis  may  run  through  all  its  stages  without  mental 
wandering. 

In  reviewing  the  maladies  with  which  tubercular  meningitis 
may  be  confounded,  it  is  incumbent  upon  us  to  bear  in  mind  the 
inflammatory  affections  of  the  lungs,  which,  in  children  especially, 
are  not  uncommonly  associated  with  delirium  and  other  symptoms 
of  a  deranged  nervous  system.  But  the  cerebral  phenomena  take 
a  different  course;  the  febrile  excitement  is  more  intense;  and  an 
examination  of  the  chest  reveals  the  cause  of  the  disturbance  of 
the  brain.  Yet  we  must  not  overlook  the  fact  that  the  signs  of 
acute  phthisis  may  be  like  those  of  acute  bronchitis  or  of  acute 
pneumonia ;  that  hence  it  may  become  a  very  perplexing  subject 
to  determine  the  precise  cause  of  the  disordered  respiration,  and 
the  presence  or  absence  of  tubercular  disease  in  the  lungs.  In- 
deed, if  the  explanation  of  the  brain  symptoms  depend  solely  on 
the  elucidation  of  this  point,  the  diagnosis  at  times  remains  un- 
certain. In  adults  the  difficulty  is  far  less,  because  the  demon- 
stration of  the  existence  or  non-existence  of  pulmonary  tubercle  is 
much  easier. 

As  an  important  point  in  the  diagnosis  of  the  tubercular  men- 
ingitis of  children,  with  reference  to  the  chest  symptoms,  Gee* 
mentions  that  the  chest  heaves  equally  well  on  both  sides,  yet  over 
a  very  large  part,  or  even  the  whole,  of  one  side,  no  respiratory 
sound  is  heard. 

Tubercular  meningitis  is  not  so  rare  in  adults  as  has  been  sup- 
posed, and  presents,  as  Seitz  in  his  recent  admirable  monograph 
has  shown,  marked  features  of  pain  in  the  head  and  temperature 
variations,!  exhibiting  a  fever  of  moderate  type,  with  irregular 


*  Reynolds 's  System  of  Medicine,  vol.  ii. 

f  Die  Meningitis  tuberculosa  der  Erwachsenen. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  139 

remissions.  The  deposit  of  tubercle  both  in  adults  and  in  chil- 
dren may  not  be  confined  to  the  head.  Indeed,  the  observations 
of  Liorilli*  teach  that  the  spinal  cord  is  frequently  implicated. 

Tubercular  meningitis  is  a  fatal  disease;  whether  invariably 
fatal,  is  as  yet  undecided.  But,  notwithstanding  the  observa- 
tions of  Rilliet,  the  weight  of  evidence  tends  in  that  direction. 

Cerebro-spinal  Meningitis. — Now  and  then  cases  of  men- 
ingitis are  encountered  in  which  the  inflammation  affects  simul- 
taneously the  membranes  of  the  brain  and  of  the  spine,  and  in 
which  the  symptoms  of  the  cerebral  malady  are  found  to  be 
blended  with  severe  pain  along  the  vertebral  column,  with  con- 
vulsions, with  rigidity  of  the  muscles,  with  perverted  cutaneous 
sensibility, — in  short,  with  the  phenomena  denoting  spinal  menin- 
gitis. But  such  sporadic  cases  are  of  rare  occurrence. f  Generally 
cerebro-spinal  meningitis  is  not  met  with  save  as  an  epidemic  dis- 
ease which  presents  itself  at  different  times  in  somewhat  dissimilar 
forms,  changing  mainly  as  the  cerebral  or  the  spinal  disturbance 
prevails,  and  varying,  moreover,  according  to  the  predominance 
of  the  constitutional  or  the  local  phenomena.  And  this  disease — 
cerebro-spinal  fever — belongs  so  clearly  to  the  group  of  fevers  that 
I  shall  there  describe  it. 

Delirium  Tremens. — The  prominent  trait  of  this  complaint 
is  delirium,  associated  with  trembling  and  with  sleeplessness.  It 
occurs  in  intemperate  persons;  yet  such  is  not  always  the  case,  for 
we  may  find  an  affection  identical  with  mania  a  potu  in  those  who 
are  not  intemperate  in  the  ordinary  acceptation  of  the  word,  but 
whose  nervous  system  has  been  racked  by  persistent  mental  anxiety, 
or  by  the  use  of  other  than  alcoholic  stimulants.  I  have  seen 
several  such  cases  within  the  last  few  years  from  the  constant 
taking  of  chloral. 

Generally,  however,  delirium  tremens  is  brought  on  by  the 
abuse  of  intoxicating  liquors.  It  is  a  current  belief,  and  one 
which  has  found  much  favor  among  habitual  drinkers,  that  a 
diminution  or  a  sudden  discontinuance  of  the  accustomed  bever- 
age is  followed   by  an   onset  of  delirium.     This   may  perhaps 

*  Archives  de  Physiologie,  1870. 

j-  Dowse  (Medical  Times  and  Gazette,  Feb.  1874)  speaks  of  the  high  tem- 
perature they  present — as  high  as  105° — and  the  absence  of  marked  reflex 
irritability  as  diagnostic. 


140  MEDICAL    DIAGNOSIS. 

happen ;  but,  if  I  am  to  take  as  a  standard  the  large  number  of 
rases  of  the  disorder  which  have  come  under  ray  care  at  the 
Philadelphia  and  Pennsylvania  Hospitals,  I  should  say  that  its 
appearance  is  most  commonly  preceded  by  a  long-continued  and 
unusually  severe  debauch,  which  finds  its  winding-up  in  an  attack 
of  mania ;  hence  that  this  occurs  in  consequence  of  an  excess, 
rather  than  of  a  diminution,  of  the  habitual  stimulus. 

Let  us  look  a  little  more  closely  at  the  mental  wandering.  It 
is  very  rarely  fierce ;  nor  is  the  patient  taken  up  wholly  with  his 
delusions.  He  pays  a  certain  amount  of  attention  to  surrounding 
objects,  answers,  perhaps  in  a  rambling  manner,  the  questions  put 
to  him,  but  fancies  that  animals  are  running  around  on  his  bed 
or  are  crawling  on  the  walls,  and  is  thereby,  or  by  some  equally 
distressing  illusion,  kept  in  horror  and  in  dread.  Or  he  imagines 
himself  to  be  engaged  in  his  ordinary  occupations,  and  gives  minute 
directions  as  to  what  he  wishes  done ;  tries  to  get  out  of  bed,  yet 
is  quite  tractable  when  thwarted  in  his  efforts.  His  hands  are 
constantly  moving,  and  his  delirium,  to  use  the  graphic  epithet  of 
Watson,  is  a  busy  one.  With  it  are  associated  great  sleeplessness, 
a  frequent,  soft  pulse,  a  moist,  coated  tongue,  and  a  clammy  skin. 

How  are  we  to  distinguish  the  malady  from  one  to  which  it 
bears  a  certain  resemblance, — acute  meningitis?  Taking  clearly- 
expressed  examples  of  each,  we  find  the  following  marks  of  dis- 
tinction:  the  pulse  is  different;  tense  and  hard  in  meningeal 
inflammation,  it  is  yielding  and  soft  in  delirium  tremens.  The 
skin  and  tongue  are  dry  and  feverish  in  the  former  affection,  moist 
in  the  latter.  Then  the  characteristics  of  the  delirium  are  dis- 
similar: and  in  the  one  disease  the  mental  wandering  is  combined 
with  severe  headache,  but  not  with  tremors;  in  the  other,  with 
tremors,  but  not  with  headache. 

Yet  in  actual  practice  the  diagnosis  is  not  always  so  easy  as  it 
might  appear  to  be  at  first  sight,  and  here  and  there  we  meet  with 
cases  presenting  symptoms  the  exact  meaning  of  which  it  is  puz- 
zling to  determine.  The  difficulty  is  mainly  occasioned  by  extreme 
cerebral  congestion,  or  by  inflammatory  action,  having  been  pro- 
duced by  the  same  exciting  cause  that  has  brought  on  delirium 
tremens.  In  this  blending  of  two  morbid  states,  the  pulse  is,  or 
soon  becomes,  tenser  than  in  pure  mania  a  potu;  the  skin  is  hotter; 
and  I  believe  the  irritability  of  the  stomach  is  more  marked  and 


DISEASES    OF    THE    BRAIN    AND    SPIN  AD    CORD.  141 

more  persistent.  In  some  instances,  convulsions,  strabismus,  and 
deep  stupor — carefully  to  be  distinguished  from  the  sleep  which 
often  announces  the  termination  of  mania  a  potu — set  all  doubt  at 
rest.  But  when  these  signs  are  not  present,  we  have  to  judge  of 
the  mischief  that  is  going  on  within  the  cranium  chiefly  by  the 
vascular  excitement,  and  by  the  activity  of  the  fever.  Yet  caution 
is  necessary  in  accepting  as  evidence  phenomena  which  may  be  of 
diverse  origin :  the  fever  may  be  the  result  of  an  intercurrent 
or  coexisting  pneumonia,  of  a  gastritis,  or  of  a  pulmonary  apo- 
plexy, as  in  a  case  I  saw  at  the  Philadelphia  Hospital  in  July, 
1860.  Only  after  a  thorough  exploration  of  the  condition  of  the 
internal  viscera  can  we  accord  to  heat  of  skin  and  bounding  pulse 
their  full  value. 

There  is  another  point  connected  with  the  diagnosis  of  the 
malady  which  it  is  necessary  to  mention,  and  chiefly  for  the  pur- 
pose of  calling  attention  to  a  common  error.  The  fact  that  a 
person  known  to  be  of  bad  habits  is  affected  with  delirium  is 
received  as  a  sure  indication  that  the  mental  delusions  have  been 
produced  by  the  abuse  of  ardent  spirits.  But  they  may  be  owing 
to  other  causes :  to  fever ;  to  a  visceral  inflammation ;  to  acute 
mania.  To  avoid  being  deceived,  we  must  lay  stress  rather  on 
the  special  character  of  the  delirium,  and  on  the  symptoms  with 
which  it  is  combined,  than  on  its  mere  presence.  In  other  words, 
delirium  in  inebriates  is  not  of  necessity  the  fruit  of  intemperance. 
In  discussing  acute  mania  we  shall  return  to  this  subject. 

The  prognosis  of  delirium  tremens  is  not  unfavorable ;  at  all 
events,  not  unfavorable  in  the  first  attack.  Indeed,  if  the  patient 
possess  sufficient  strength  of  will  to  reverse  his  habits,  and  be  dis- 
posed to  take  his  first  punishment  as  a  warning,  it  is  powerful  for 
good,  instead  of  for  evil.  But,  unfortunately,  most  attempts  at 
reform  do  not  last  long,  and  sooner  or  later  the  drunkard  dies  a 
drunkard's  death.  The  fatal  issue  is  occasionally  brought  on  by 
an  intercurrent  inflammation,  especially  of  the  lung;  sometimes, 
after  the  subsidence  of  the  urgent  cerebral  symptoms,  the  patient 
dies  very  unexpectedly,  and  there  are  no  morbid  appearances  in 
the  brain  or  its  membranes  to  account  for  the  abrupt  extinction  of 
life.  In  many  instances,  however,  of  these  sudden  deaths,  a  large 
amount  of  serum  is  found  in  the  ventricles,  or  in  the  subarachnoid 
spaces. 


142  MEDICAL    DIAGNOSIS. 

Acute  Mania. — It  would  be  obviously  out  of  place  to  attempt 
to  give,  in  a  work  ou  medical  diagnosis,  a  detailed  account  of  any 
of  the  forms  of  insanity;  but,  in  its  acute  variety  especially,  it 
resembles  other  affections  of  the  nervous  system  so  closely  that  it 
cannot  be  wholly  passed  over. 

There  are  mainly  two  disorders  with  which  acute  mania  is  liable 
to  be  confounded, — acute  meningitis  and  delirium  tremens;  and  we 
shall  for  our  purposes  best  learn  the  manifestations  of  acute  mania 
by  contrasting  it  with  these  maladies. 

From  acute  meningitis  mania  differs  in  these  essential  par- 
ticulars :  the  premonitory  symptoms  of  the  former  are  headache, 
drowsiness,  and  often  a  sense  of  tingling  and  of  numbness  in  the 
extremities;  these  signs  are,  however,  soon  succeeded  by  the  se- 
verer headache,  tense  pulse,  high  fever,  and  optical  illusions  of  the 
developed  disease.  The  premonitory  symptoms  of  acute  mania, 
on  the  other  hand,  have  generally  existed  for  a  longer  time  before 
the  marked  outbreak ;  some  singular  change  of  manner  or  of  mode 
of  thought  commonly  precedes  the  first  violent  attack  of  insanity, 
except  in  those  cases  in  which  the  overthrow  of  reason  results 
from  a  sudden,  great  grief,  or  from  a  violent  shock  to  the  nervous 
system.  Further,  when  the  delusions  have  taken  full  possession 
of  the  mind,  the  patient  attempts  to  act  up  to  them,  and  his  bodily 
strength  enables  him  to  do  so.  He  has  little  if  any  fever;  no 
spasms;  his  pupils  are  not  contracted;  his  stomach  is  not  irri- 
table ;  he  does  not  suffer  from  headache,  or  at  least  does  not  in 
any  way  complain  of  his  head.  It  is  needless  to  point  out  how 
all  this  differs  from  acute  inflammation  of  the  brain. 

There  is  but  little  difficulty  in  discriminating  between  typical 
cases  of  delirium  tremens  and  of  acute  mania.  The  anxious  and 
distressed  countenance,  the  alarm,  the  good-natured  loquacity  and 
restlessness  of  the  patient,  his  moist  skin,  compressible  pulse,  and 
creamy  tongue,  are  phenomena  very  different  from  the  ravings  and 
excitement,  or  the  stubborn  silence  alternating  with  the  wildly- 
expressed  hallucinations,  of  insanity.  Yet  there  are  cases  in 
which  it  is  not  easy  to  tell  if  the  delusions  are  really  due  to  in- 
temperance:  cases  of  insanity  excited  by  drink  in  persons  predis- 
posed to  mania.  It  may,  indeed,  at  first  be  impossible  to  decide 
upon  their  nature,  and  upon  the  share  the  drinking  has  in  their 
production.     A  few  days,  however,  ordinarily  remove  all  uncer- 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  143 

tainty ;  the  person  who  is  thought  to  be  merely  delirious  is  seen 
to  become  frantic  after  an  intermission  of  quiet,  or,  unlike  what 
happens  in  mania  a  potu,  to  be  still  out  of  his  mind  after  he 
has  had  several  sound  sleeps.  In  one  instance,  in  which  much 
doubt  existed  as  to  the  diagnosis,  the  patient  solved  the  doubt  by 
jumping  out  of  bed  after  having  been  quietly  sleeping  for  hours, 
and,  in  a  state  of  wild  excitement,  knocking  down  the  nurse  who 
tried  to  prevent  her  from  leaving  the  room.* 

Diseases  marked  by  Sudden  Loss  of  Consciousness  and  of 
Voluntary  Motion, 

The  chief  diseases  of  this  class  are  apoplexy,  sun-stroke,  and 
catalepsy.  Epilepsy,  too,  might  assert  its  claims  to  be  here  re- 
garded ;  but  it  is  more  convenient  to  consider  it  with  the  con- 
vulsive aiFections. 

Apoplexy. — This  is  coma  coming  on  rapidly,  in  consequence 
of  the  compression  of  the  brain  by  extravasated  blood.  At  all 
events,  hemorrhage  is  the  condition  by  far  the  most  commonly 
linked  to  the  comatose  symptoms;  in  comparatively  rare  cases 
only  does  the  pressure  upon  the  brain  result  from  turgescence  of 
the  vessels,  or  from  an  effusion  of  serum. 

The  malady  has  sometimes  no  prodromata;  but  not  unfrequently 
it  is  preceded  by  great  depression  of  spirits,  by  attacks  of  loss  of 
memory,  by  illusions,  by  vitiated  perceptions,  by  vertigo,  or  by 
odd  sensations  in  the  head. 

The  seizure  is  generally  very  sudden,  and  the  coma  quickly 
developed.  The  patient  falls  to  the  ground,  bereft  of  all  con- 
sciousness. In  other  instances,  before  he  sinks  into  the  comatose 
sleep,  there  will  be  more  or  less  pain  in  the  head,  sickness  at  the 
stomach,  heaviness  and  confusion  of  thought,  or  even  slight  con- 
vulsions. Such  gradual  cases,  Abercrombie  tells  us,  are  more 
dangerous  than  those  of  abrupt  origin.  Again,  we  may  even 
have  convulsions  a  prominent  feature  almost  from  the  onset. 

"When,  whatever  its  beginning,  the  attack  has  reached  its  height, 
it  presents  these  well-known  features :  the  patient  lies  as  if  in  a 
deep  sleep,  breathing  laboriously  and  noisily,  and  each  snoring 

*  For  fuller  information  on  the  diagnosis  of  acute  mania,  see  particularly 
Dr.  Henry  Maudsley's  work,  and  Griesinger's  Mental  Pathology. 


144  MEDICAL    DIAGNOSIS. 

inspiration  is  followed  by  a  flapping  of  the  cheeks  in  expiration. 
The  pulse  is  slow,  full,  at  times  irregular ;  the  carotids  throb 
violently,  and  the  increased  pulsation  is  particularly  noticed  in 
large  effusions,  whether  of  blood  or  of  serum;  there  is  difficulty 
of  deglutition ;  the  pupils  are  immovable,  and  either  contracted  or 
dilated;  the  eye  is  half  open.  All  thought,  all  sensation,  all  voli- 
tion, is  suspended ;  the  limbs  are  motionless,  flaccid,  and  when 
lifted  fall  passively  and  to  all  appearance  lifeless  to  the  ground. 
Occasionally,  their  muscles  are  rigid  ;  but,  save  when  the  apoplexy 
is  very  extensive,  reflex  contractions  can  be  excited  in  them. 

If  the  patient  recover  from  the  comatose  state,  he  does  so  gen- 
erally in  a  short  time ;  in  a  few  hours,  unless  the  lesion  be  very 
great,  the  intellectual  faculties  begin  to  resume  their  sway,  and 
all  the  functions  of  the  body  are  slowly  restored  to  their  natural 
condition.  Yet  there  is  a  palpable  exception  to  this  in  the  mus- 
cular system.  Paralysis  of  one  side  is  apt  to  remain  long  after 
everything  else  presents  a  normal  look ;  nay,  it  may  be  a  sequel 
lasting  for  years,  or  even  permanently. 

The  temperature  variations  in  apoplexy  are  of  interest,  and 
may  be  turned  to  useful  diagnostic  account.  Bourneville,  who 
has  carefully  investigated  the  matter,  has  shown  that  the  tem- 
perature of  the  body  is  at  first  decidedly  lowered,  but  this  is  soon 
followed  by  a  stationary  normal  period  and  by  a  rapid  rise,  which 
again,  when  the  patient  recovers,  is  succeeded  by  a  return  to  the 
natural  body  heat.  In  severe  cases  where  large  hemorrhages 
take  place,  the  temperature  never  rises,  or  only  rises  to  fall  with 
the  recurrence  of  the  fatal  bleeding.  If  the  stationary  period  be 
short  or  absent,  and  the  body  heat  rise  therefore  almost  continu- 
ously after  the  primary  depression,  the  prospects  of  recovery  are 
also  gloomy. 

Apoplexy  is  very  apt  to  happen  after  dinner  and  during  sleep, 
and  is  most  common  when  sudden  variations  of  temperature  are 
most  frequent.  Liddell  has  shown  that  attacks  are  more  usual  in 
the  spring.  In  New  York  he  found  the  mortality  greatest  at  that 
time  of  year.* 

One  attack  of  apoplexy  is  likely,  sooner  or  later,  to  be  followed 
by  another  ;  and  the  reason  of  this  is,  that  the  predisposing  cause 


*  Treatise  on  Apoplexy,  New  York,  1873. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  145 

is  generally  of  a  persistent  character, — an  organic  cardiac  malady, 
especially  hypertrophy  of  the  left  ventricle  or  tricuspid  regurgi- 
tation ;  Bright's  disease ;  degeneration  of  the  cerebral  arteries ; 
disseminated  sclerosis,  or  softening  of  the  brain.  But  recent  re- 
searches have  rendered  it  likely  that  the  extravasation  of  blood  is 
always  due  to  the  same  immediate  cause, — to  rupture  of  miliary 
aneurisms  on  the  minute  arteries,  which  are  constantly  found  to  be 
diseased.* 

Now,  is  there  anything  at  the  time  of  the  apoplexy,  or  after  its 
most  urgent  symptoms  have  passed  away,  by  which  we  can  recog- 
nize whether  the  pressure  on  the  brain  results  from  a  clot,  from 
a  serous  effusion,  or  from  a  turgescence  of  the  cerebral  vessels  ? 
And,  again,  do  the  morbid  manifestations  furnish  any  clue  to  the 
seat  of  the  hemorrhage?  With  reference  to  the  former  question, 
all  clinical  experience  forces  us  to  admit  that,  in  any  of  the  states 
mentioned,  the  actual  signs  may  be  the  same ';  and  that  we  never 
can  be  quite  certain  of  the  non-existence  of  a  clot.  It  is  true 
that  when  the  apoplectic  symptoms  abate  rapidly ;  when  thought, 
however  confused,  soon  returns;  when  the  limbs  are  not  paralyzed, 
or  are  so  but  imperfectly  and  for  a  short  time, — we  have  strong 
reason  for  believing  that  congestion  simply,  lies  at  the  root  of  the 
disturbance ;  that,  in  other  words,  the  case  is  one  of  those  called 
simple  apoplexy.  But  it  is  never  possible  to  give  a  positive 
opinion,  since  a  clot  near  the  periphery  of  the  brain  may  occasion 
the  same  phenomena  as  those  specified. 

With  regard  to  a  rapid  effusion  of  serum,  the  difficulty  of 
distinction  is  quite  as  great,  or  even  greater.  In  fact,  the  only 
differential  signs  which  were  formerly  claimed  for  serous  apo- 
plexy, namely,  pallor  of  face  aud  feebleness  of  pulse,  are  now 
known  to  be  very  common  in  large  sanguineous  effusions;  and 
when  we  analyze  the  symptoms  of  the  cases  recorded  by  Aber- 
crombie,  by  Morgagni,  and  by  Andral, — for  the  descriptions  of 
older  authors  respecting  this  affection  are  not  to  be  trusted,  and 
most  modern  authorities  seem  to  pass  it  by  as  wholly  unworthy  of 
notice, — we  find  absolutely  nothing  that  can  be  looked  upon  as 
even  pointing  to  a  diagnosis.     In  a  case  which  came  under  my 


*  Charcot  and  Bouchard,  Arch,  de  Physiol.,  1868;  also  Charcot,  Maladies 
des  Yieillards. 

10 


14(5  MEDICAL    DIAGNOSIS. 

observation  some  years  since,*  the  respiration  was  not  noisy,  nor 
Mas  there  napping  of  the  cheeks,  or  the  least  discernible  move- 
ment of  any  portion  of  the  body;  yet  I  am  not  aware  that  any 
of  these  points  can  be  regarded  as  diagnostic. 

The  scat  of  the  hemorrhage  can  ordinarily  be  detected  with 
somewhat  more  certainty  than  the  cause  of  the  cerebral  pressure ; 
it  could  be  detected  with  yet  greater  certainty,  were  it  not  that 
the  extravasation  so  often  takes  place  into  an  already  diseased 
brain.  In  the  vast  majority  of  instances,  the  blood  is  effused  into 
one  of  the  corpora  striata  and  the  optic  thalami,  and  we  find, 
in  consequence,  only  one-sided  paralysis.  If  the  lesion  be  in  both 
hemispheres,  the  palsy  is  on  both  sides  of  the  body,  although 
almost  invariably  more  complete  on  one  side  than  on  the  other. 
Yet  a  double-sided  palsy  does  not  justify  an  absolute  opinion  that 
the  extravasation  of  blood  into  the  brain-substance  is  double- 
sided.  It  betokens  also  an  effusion  into  the  ventricles.  But 
ventricular  hemorrhage  is  distinguished  by  profound  coma  and 
by  tonic  contraction  of  the  muscles,  or  by  tonic  alternating  with 
clonic  spasms. 

Hemorrhage  limited  to  the  thalamus  gives  rise  to  markedlv 
increased  temperature  of  the  palsied  side,  but  exhibits,  even  when 
on  the  left  side,  no  aphasia,  as  we  are  apt  to  find  in  affections  in 
and  around  the  left  corpus  striatum.  A  large  bleeding  into  the 
anterior  lobe  deprives  the  patient  of  the  sense  of  smell  on  the  side 
on  which  it  has  happened. 

Hemorrhage  into  the  corpora  quad ri gem ina  presents  most  fre- 
quently this  combination  of  symptoms :  muscular  tremblings, 
convulsions,  impairment  of  sight  and  alteration  of  the  pupils. 
Cerebellar  hemorrhage  gives  rise  to  very  temporary  loss  of  con- 
sciousness ;  to  relaxation  of  the  muscles  of  the  limbs  without 
paralysis  or  impaired  sensibility  ;  and  to  frequent  vomiting,  f  In 
hemorrhage  into  one-half  of  the  pons,  there  is  palsy  of  the  ex- 
tremities on  one  side,  and  of  the  face  on  the  other. t  There  may 
also  be  hyperesthesia  in  some  parts  of  the  body,  and  amaurosis.§ 
In  lesion  of  the  pons,  too,  we  find  an  exception  to  the  rule  that 

*  Charleston  Medical  Journal  and  Review.  March.  1859. 
t  Hillairet.  Arch.  Gen.  de  Med..  1858,  tome  xi. 
%  Gubler.  Gaz.  Hebdom.,  18-58.  18S 
\  Brown-Sequard. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  147 

the  lateral  deviation  of  the  eyes  and  head,  a  sign  so  commonly 
present  in  apoplexy,  is  toward  the  side  of  the  brain  affection.* 

In  cortical  bleedings  we  are  apt  to  have  convulsions  and  but 
slight  palsy.  Hemorrhage  limited  to  the  arachnoid,  with  the 
blood  poured  into  the  subarachnoid  spaces,  occasions  ordinarily 
pain  in  the  head,  somnolency,  and  profound  coma  without  paral- 
ysis, and  without  anaesthesia  or  slow  pulse,  but  with  relaxation 
of  the  muscles,  and  sometimes  with  convulsions ;  now  and  then 
the  symptoms  assume,  to  all  appearance,  a  remittent  course.  It 
is  a  very  fatal  form  of  apoplexy,  occurring  chiefly  in  new-born 
children,  and  after  injuries  to  the  head,  or  from  the  giving  way 
©f  a  diseased  and  widened  artery,  or  in  consequence  of  a  rupture 
of  one  of  the  sinuses  of  the  dura  mater. 

When  the  effusion  of  blood  takes  place  between  the  dura  mater 
and  the  arachnoid,  it  is,  as  Virchow  has  proved,  generally  the 
ultimate  result  of  an  inflammation  and  of  subsequent  changes  of 
the  inner  surface  of  the  dura  mater.  On  close  inquiry,  the  pre- 
cursory symptoms  of  a  disease  of  the  membrane  may,  perhaps,  be 
traced  by  the  constant  and  localized  pain,  and  the  nocturnal  rest- 
lessness. But  the  symptoms  of  the  "  hematoma"  are  as  obscure 
as  its  pathology ;  indeed,  by  some,  by  Huguenin  especially,  the 
affection  is  looked  upon  as  originally  a  hemorrhage  from  rupture 
of  the  veins  on  the  brain-surface.  It  happens  generally  after  fifty 
years  of  age,  in  the  decrepit  or  in  those  suffering  from  pernicious 
ansemia,  scurvy,  emphysema,  hooping-cough,  alcoholism,  or  after 
head  injuries.  When  the  cyst  ruptures,  which  it  may  not  do  for 
years,  the  signs  are  those  of  an  apoplectic  condition,  lasting  for 
eight  or  ten  days. 

What  has  been  said  of  the  symptoms  pointing  to  the  seat  of 
lesion  is  exclusively  based  on  well-attested  clinical  experience. 
The  recent  researches  on  the  localization  of  the  cerebral  functions 
above  alluded  to  promise  to  make  our  knowledge  of  the  seat  of 
the  apoplexy  very  much  more  definite. 

Let  us  now  examine  how  the  diagnosis  of  apoplexy  can  be  de- 
termined, and  how  this  malady  may  be  distinguished  from  other 
states  which  produce  rapid  loss  of  consciousness,  or  sudden  paral- 
ysis.   Not  to  mention  epilepsy, — the  phenomena  of  which  we  shall 

*  Bastian,  Paralysis  from  Brain  Disease. 


148  MEDICAL    DIAGNOSIS. 

further  on  contrast  with  those  of  apoplexy,  and. shall  observe  to 
differ  chiefly  in  the  prominence  of  the  convulsions;  or  meningitis, 
— in  which  fever,  headache,  and  other  signs  of  an  acute  cerebral 
disease  precede  insensibility;  or  a  tumor, — which,  save  in  the 
rarest  instances,  leads  only  very  gradually  to  a  comatose  condition ; 
or  sun-stroke, — belonging  to  the  same  group  as  cerebral  hemor- 
rhage, yet  presenting  points  of  contrast,  which  will  shortly  engage 
our  attention, — we  find,  excluding  concussion  and  compression  as 
belonging  more  strictly  to  surgical  diagnosis,  these  morbid  states 
liable  to  be  mistaken  for  apoplexy  : 

Insensibility  from  Drink,  or  from  Narcotic  Poisons  ; 

Uraemia  ;  » 

Syncope ; 

Asphyxia  ; 

Acute  Softening; 

Sudden  Extensive  Paralysis  ; 

Obstructions  of  the  Cerebral  Arteries; 

Protracted  Sleep; 

Cerebral  Hysteria; 

Aphasia. 

Insensibility  from  Drink,  or  from  Narcotic  Poisons. — Both  these 
conditions  are  sometimes  very  difficult  to  distinguish  from  the 
coma  of  apoplexy ;  and  if  we  are  not  cognizant  of  the  circum- 
stances preceding  their  development,  we  have  only  these  points  to 
guide  us:  in  intoxication  there  is  a  strong  smell  of  whiskey,  gin, 
or  whatever  lienor  has  produced  it,  emanating  from  the  mouth,  a 
point  which  would  be  conclusive  were  it  not  that  apoplexy  may 
come  on  in  the  drunken  state,  and  the  man,  although  unconscious, 
is  not  often  entirely  bereft  of  all  power  of  motion, — he  is  certainly 
not  paralyzed.  Moreover,  the  pulse  is  not  slow,  it  is  frequent; 
the  pupils  are  generally  dilated ;  the  eye  is  injected,  shows  no 
lateral  deviation ;  and  the  symptoms  become  suddenly  much  ame- 
liorated after  the  inhalation  of  ammonia,  or  after  the  stomach 
has  been  emptied  of  its  contents.  In  narcotic  poisoning,  especially 
if  from  opium,  the  pupils  are  very  much  contracted,  and  we  are 
likely  to  encounter  repeated  vomiting,  and  a  gradual  intensification 
of  the  coma.  The  patient,  however,  unless  death  be  close  at  hand, 
can  be  momentarily  roused  from  his  deep  sleep ;  and  his  calm 
breathing  is  unlike  the  stertor  of  apoplexy.     But  when  the  hem- 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  149 

orrhage  has  taken  place  into  the  pons  Varolii,  the  diagnosis  is  very 
difficult,  especially  if  the  bleeding  be  extensive,  for  then  we  are  apt 
to  have  a  contraction  of  both  pupils,  and  the  respiration  may  not 
be  stertorous;  nor  is  there  always  at  first  paralysis.  Yet  this 
subsequently  appears,  and  thus  the  detection  of  the  cause  of  the 
insensibility  is  rendered  easier.*  A  symptom  of  great  diagnostic 
significance,  too,  is  the  occurrence  of  convulsions.  Still,  as  Russell 
Reynolds  shows,  this  may  occasionally  happen  in  opium  poisoning, 
and  is  not  very  rare  in  children. 

Nitrobenzole,  which  operates  as  a  narcotic  poison  in  vapor 
as  well  as  in  a  liquid  state,  may,  in  rapidly  fatal  cases,  produce 
coma,  which  may  be  mistaken  for  the  insensibility  of  apoplexy. 
But  the  poison  leads  quickly  to  death  when  coma  has  been  in- 
duced, and  is  detected  by  its  strong  odor,  resembling  that  of  bitter 
almonds. f  Poisoning  by  drinking  chloroform  gives  rise  to  many 
of  the  symptoms  of  apoplexy ;  it  is  discerned  by  the  odor  of  the 
breath,  by  the  quick  and  tumultuous  action  of  the  heart  which 
accompanies  the  stertorous  breathing,  by  the  relaxation  of  the 
limbs,  by  the  death-like  aspect  of  the  face,  by  the  widely-dilated 
pupils,  and  by  the  complete  general  ana3Sthesia4 

Uraemia. — The  strong  point  here  in  the  diagnosis  is  that  the 
coma  is  preceded  by  convulsions.  The  exceptional  instances  are 
very  few  indeed.  An  examination  of  the  urine  adds,  of  course, 
to  the  certainty  of  the  case ;  but,  for  obvious  reasons,  it  cannot 
always  aid  us  at  once.  Moreover,  albumen — not,  however,  I 
believe,  in  large  amounts — may  occur  in  the  urine  after  convul- 
sions that  were  not  ursernic.  Puffy  eyelids  and  swollen  ankles,  a 
coma  not  profound,  a  peculiar  stertor  seeming  to  emanate  from  the 
mouth,  very  low  body  heat,  not  rising  even  as  the  case  lasts,  are 
symptoms  that  belong  to  ursernic  coma. 

Syncope — Asphyxia. — The  loss  of  consciousness  in  either  of  these 
states  is  as  striking  as  in  apoplexy.  But  there  is  this  decided 
difference:  the  suspension  of  thought  and  of  volition  in  a  fainting- 
fit is  due  to  failure  of  the  circulation :  hence  the  pulse  is  hardly 
or  not  at  all  felt,  instead  of   being  full,  as  it  is  in  apoplexy. 

*  See  an  interesting  case  mentioned  by  Hughlings  Jackson,  London  Hos- 
pital Beports,  vol.  i.,  1864. 

f  Taylor,  Guy's  Hospital  Keports,  vol.  x.,  3d  Series. 

X  As  in  the  case  reported  in  L'Union  Medicale,  October,  186L 


150  MEDICAL    DIAGNOSIS. 

Further,  the  pallor  of  the  face,  the  quiet  respiration,  and  the 
short  duration  of  the  syncope  mark  plainly  the  one  affection  from 
the  other.  And  with  reference  to  asphyxia,  the  turgid  and  livid 
face,  the  bluish  lip,  the  distressed  and  embarrassed  breathing  pre- 
ceding the  convulsions,  and  the  loss  of  consciousness,  show  clearly 
that  the  disturbance  affects  primarily  the  lungs,  and  does  not  reside 
in  the  brain. 

Acute  Softening. — This  may  give  rise  to  symptoms  so  similar 
to  those  of  cerebral  hemorrhage  that  a  differential  diagnosis  is 
impossible.  Especially  does  this  happen  if  the  disease  manifest 
itself  suddenly,  which  Rostan  informs  us  occurred  in  one-half  of 
the  cases  he  noted.  In  those  of  more  gradual  origin,  a  feeling  of 
numbness,  deterioration  of  memory,  irritability  of  temper,  slight 
impairment  of  motion,  and  a  vacant,  dull  look,  are  noticed  for 
some  time  before  the  attack.  Occasionally  delirium  immediately 
precedes  the  loss  of  consciousness.  Now,  this  may  be  perfect,  or 
imperfect,  or  even  wholly  wanting, — for  the  patient  may  become 
paralyzed,  after  being  merely  confused  or  feeling  distressed,  but 
without  losing  his  consciousness.  The  palsy  is  at  times  attended 
with  hyperesthesia  and  with  rigidity  of  the  limbs ;  some  disorder 
of  sensation  or  some  muscular  twitching  is  almost  always  present. 

But  it  is  by  the  after-symptoms  that  we  most  easily  separate 
acute  softening  from  apoplexy.  In  the  latter,  after  the  shock  is 
over,  a  gradual  improvement  takes  place,  very  obvious  as  regards 
the  mental  faculties  and  the  power  of  articulation  ;  in  the  former, 
the  mind  remains  obtuse,  or  greatly  impaired,  and  there  is  other- 
wise but  slight  amelioration  ;  defects  of  sensibility  are  particularly 
apt  to  be  noticed,  and  the  paralysis  is  apt  to  be  irregular  and  more 
limited  than  in  apoplexy.  On  the  other  hand,  as  Bourneville 
shows,  the  temperature  falls  more  rapidly.  A  significant  sign, 
too,  of  acute  softening  is  an  increased  secretion  from  the  mouth 
and  eye.* 

Sudden  Extensive  Paralysis  without  Coma. — This  is  not  a  trait 
of  apoplexy,  although  it  is  a  common  error  to  suppose  that  a 
sudden  palsy  is  produced  by  hemorrhage  into  the  brain.  Sudden 
extensive  paralysis  without  coma  is  ordinarily  owing  to  softening 
of  the  brain ;  but  it  may  be  due  to  hemorrhage  into  the  spinal 

*  Durand  Fardel,  Maladies  des  Vieillards. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  151 

column.  Palsy  from  this  source,  unlike  that  caused  by  cerebral 
hemorrhage,  is  almost  invariably  double-sided,  is  accompanied 
by  severe  spinal  pain,  and,  if  the  extravasation  have  taken  place 
into  the  spinal  meninges,  by  tonic  spasms,  like  those  of  tetanus. 

Obstructions  of  the  Cerebral  Arteries. — If  a  cerebral  artery  be 
suddenly  closed  by  a  fibrinoid  vegetation  being  washed  into  it, 
apoplectic  symptoms  arise.  We  may  suspect,  for  we  never  can  be 
quite  certain,  that  an  arterial  obstruction  is  the  cause  of  the  dis- 
turbance of  the  brain,  if  the  patient  be  young ;  or  if  he  be  labor- 
ing under  an  acute  or  subacute  endocardial  inflammation,  or  a 
chronic  valvular  trouble  in  which  fragments  of  vegetations  may 
be  broken  off;  or  if  within  a  brief  period  of  one  another  several 
incomplete  attacks  have  occurred  before  a  perfect,  and  generally 
fatal,  comatose  condition  sets  in.  The  usual  locality  of  the  im- 
paction is,  according  to  Virchow,  in  the  middle  cerebral  artery ; 
and  the  consequences  of  the  interrupted  circulation  are  at  once 
perceived  in  the  adjacent  centre  of  motion, — the  corpus  striatum. 
The  palsy  which  ensues  in  connection  with  the  apparently  apo- 
plectic phenomena  is  one-sided;  and  the  facial  paralysis  is  on 
the  same  side  with  that  of  the  limbs.  Other  peculiarities  of  the 
hemiplegia  are,  that  its  onset  is  not  of  necessity  attended  with 
loss  of  consciousness,  or  that  this  is  slight  and  of  short  duration ; 
that  the  palsy  is  often  quickly  followed  by  gangrene  of  the  ex- 
tremities ;  or  is  associated  with  disturbance  of  the  kidneys,  or  with 
enlargement  of  the  spleen  and  tenderness  in  the  splenic  region, 
due  to  changes  in  the  organs,  produced  by  an  impaction  of  fibrin. 
Just  as  in  apoplexy,  we  may  find  in  obstructions  of  the  vessels, 
softening  as  a  result  of  the  accident;  and  the  symptoms  of  this 
sequel  are  not  different  from  what  they  are  when  softening  is 
owing  to  more  usually  accredited  causes.* 

Occasionally  the  clot  is  not  washed  into  the  brain,  but  is  formed 
in  one  of  its  arteries.     The  thrombosis  may  extend  thence  as  far 


*  But  we  shall  learn  more  and  more  to  look  upon  thrombosis  and  emboli  as 
among  the  ordinary  causes  of  softening  of  the  brain.  M.  Lancereaux  ("  De 
la  Thrombose  et  de  l'Embolie  cerebrale")  states  that  of  22  cases  he  observed, 
16  were  connected  with  arterial  obstruction  ;  and  in  a  clinical  lecture  (London 
Lancet,  Sept.  1875)  Hughlings  Jackson  declares  that,  excluding  softening 
about  tumors  and  from  gross  causes  similarly  obvious,  he  knows  nothing  of 
softening  of  the  brain  except  from  blocking  of  its  vessels. 


152  MEDICAL    DIAGNOSIS. 

as  the  common  carotid.  Hasse,  who  has  placed  two  such  cases 
on  record,  mentions  that,  independently  of  the  cerebral  symptoms, 
they  may  be  recognized  by  the  absence  of  pulsation  in  the  carotid 
of  the  affected  side,  and  by  its  tense,  cordy  feel.*  Thrombosis,  as 
we  ordinarily  see  it,  occurs  like  apoplexy  in  elderly  persons,  and, 
though  it  may  be,  is  not  apt  to  be  sudden ;  there  are  warnings  of 
the  attack,  and  the  signs  of  a  weak  heart,  and  the  coma  is  rarely 
as  profound  as  in  apoplexy. 

Protracted  Sleep. — While  recovering  from  acute  diseases,  the 
sick  often  sleep  profoundly  and  for  a  long  time.  Yet  there  is 
little  likelihood  of  confounding  this  with  the  sleep  of  apoplexy ; 
for  the  antecedent  circumstances  reveal  the  meaning  of  this  resto- 
ration of  nature.  Sometimes,  however,  persons  sink  into  a  deep 
and  prolonged  slumber  without  any  previous  ailment.  Medical 
literature  furnishes  a  number  of  such  instances.  In  one  recorded 
by  Dr.  Cousins,f  the  tendency  to  somnolency  has  lasted  for  years. 
The  patient  frequently  sleeps  three,  and  sometimes  five,  days  at  a 
time.  When  he  awakes  he  is  well.  In  a  case  which  I  saw  with 
Dr.  Weir  Mitchell,!  the  slumberer  was  aroused  several  times  by 
the  exciting  influence  of  electricity ;  but  this  finally  lost  its  effect, 
and  she  relapsed  into  a  sleep  from  which  she  awoke  no  more. 
These  cases  may  give  the  impression  of  apoplexy,  yet  they  do  not 
resemble  it  strictly.  They  are  unlike  it  in  the  gentle,  noiseless 
breathing;  in  the  feeble  pulse;  in  the  occasional  motion  of  the 
body;  and  in  the  protracted  unconsciousness. 

Cerebral  Hysteria.— -The  actual  similitude  and  the  points  of 
contrast  between  this  curious  state  and  apoplexy  may  be  learned 
from  the  following  sketch  : 

A  married  lady,  of  a  remarkably  susceptible  and  nervous  dis- 
position, had  been  for  many  months  suffering  from  amenorrhoea 

*  Zeitschr.  fur  Ration.  Pathol.,  Band  iv.  There  may  be  other  causes,  too, 
of  cerebral  embolism  than  those  indicated.  For  instance,  a  case  of  carbuncle 
ending  in  embolism  of  the  middle  cerebral  artery  is  described  in  the  Med. 
Times  and  Gazette,  Feb.  1869.  Cases  of  fat-globules  in  the  smaller  arteries 
leading  to  a  fatty  embolism  have  been  analyzed  by  Busch.  See  Virchow's 
Archiv,  as  quoted  in  Brit,  and  For.  Med.-Chir.  Rev.,  April,  1869,  p.  551. 

|  Medical  Times  and  Gazette,  April,  1863.  See  also  a  somewhat  similar 
case,  New  York  Medical  Journal,  Dec.  1867. 

%  Described  by  him,  Transactions  of  College  of  Physicians  of  Philadelphia, 
1856. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  153 

and  from  sluggish  action  of  the  bowels.  She  was  at  the  same 
time  troubled  with  a  constant  cough,  evidently  dependent  upon  a 
deposition  of  tubercles  in  one  of  the  lungs.  She  had  been  in  very 
bad  health,  but  by  the  steady  employment  of  tonics,  and  the  bene- 
ficial eifects  of  a  sea-voyage,  her  symptoms  were  much  amended. 
Her  appetite  improved,  and  she  began  to  gain  flesh,  and  to  take 
exercise  without  fatigue.  She  was,  however,  troubled  with  head- 
ache, and  with  pain  at  the  lower  part  of  the  abdomen.  On  one 
occasion  in  the  evening  I  ordered  her  some  cathartic  medicine; 
and  in  the  morning  she  was  better  than  usual,  and  in  the  liveliest 
spirits.  A  few  hours  afterward,  I  was  sent  for,  and  found  her  in- 
sensible. She  had  complained  of  a  sudden,  sharp  cramp  near  the 
umbilicus,  and  had  then  ceased  to  speak.  She  remained  uncon- 
scious for  about  twelve  hours ;  yet  not  wholly  so,  for  every  now 
and  then  she  opened  her  eyelids,  muttered  a  word  or  two,  and  a 
pleasant  smile  flitted  over  her  countenance;  but  she  soon  relapsed 
into  her  deep  slumber.  Her  thumbs  were  drawn  inward;  she 
had  occasionally  convulsive  movements ;  the  breathing  was  rapid, 
but  not  noisy;  the  pulse  feeble, — at  first  slow,  then  frequent;  her 
eyes  squinted  in  the  most  decided  manner.  Stimulants  and  anti- 
spasmodics were  freely  given,  but  without  much  benefit,  for  she 
recovered  from  her  lethargy  only  with  the  setting  in  of  the  most 
violent  paroxysmal  pains  in  the  abdomen,  shooting  down  the" 
thigh,  and  accompanied  by  contractions  of  the  muscles  and  by 
exquisite  local  tenderness.  The  next  day,  without  much  abate- 
ment of  the  suffering,  she  was  perfectly  conscious ;  but  still  she 
squinted, — nay,  was  totally  blind,  and  remained  so  for  two  days. 
During  this  time  a  menstrual  discharge  commenced,  which  in  part 
relieved  the  abdominal  pain.  The  head  symptoms  were,  if  the 
expression  be  admissible,  a  metastasis  of  hysteria  from  the  ovaries 
to  the  brain.  It  is  needless  to  point  out  how  this  display  of  hys- 
teria differed  from  apoplexy. 

Aphasia. — By  this  term  is  meant  loss  of  the  faculty  of  expres- 
sion of  thought,  in  consequence  of  loss  either  of  the  faculty  of 
speech,  or  of  that  of  communicating  thought  by  writing  or  by 
gestures.  The  patient  may  be  deprived  of  the  ability  of  express- 
ing himself  in  one  of  these  ways,  or  in  all.  The  loss  of  speech  is 
the  most  common,  and  is  apt  to  be  associated  with  a  very  decided 
impairment  of  memory  and  an  enfeeblement  of  intelligence.    The 


154  MEDICAL    DIAGNOSIS. 

disorder  may  be  temporary,  lasting  but  a  few  hours  or  some  days, 
or  it  may  continue  for  months  or  years.  During  its  course  the 
affected  person  is  incapable  of  recalling  words  to  give  utterance  to 
his  ideas;  or,  if  he  can  recall  the  words  to  the  mind,  and  thus  think, 
he  cannot  express  them.  He  has  lost,  to  use  the  language  of  Trous- 
seau, to  whom,  more  than  to  any  one  else,  we  are  indebted  for  our 
knowledge  of  the  subject,  "  at  the  same  time,  to  a  greater  or  less 
degree,  the  memory  of  words,  the  memory  of  the  acts  by  the  aid 
of  which  the  words  are  articulated,  and  intelligence;  but  all  the 
faculties  are  not  equally  lost,  and,  however  damaged  the  intelli- 
gence, it  is  less  so  than  the  memory  of  the  acts  of  phonation,  and 
this  less  so  than  the  memory  of  words." 

Very  often  the  patient  has  but  a  few  words  at  his  control :  he 
says  "yes"  or  "  no"  for  everything,  and  appears  angry  that  he  can 
say  no  more ;  or  he  uses  wrong  words,  knowing  perhaps  that  they 
are  wrong,  and  sometimes  only  those  of  a  profane  kind ;  or  he 
confuses  merely  some  syllables  in  the  words  he  employs;  or  he 
may  not  be  able  to  utter  a  word,  using  altogether  unintelligible 
expressions.  Yet,  while  in  this  condition,  there  is  no  defect  in 
the  tongue,  or  lips,  or  palate,  to  account  for  the  inability  to  talk ; 
they  are  as  healthy  as  usual ;  the  act  of  swallowing  is  easily  per- 
formed; and  even  where  the  aphasia  is  complicated  with  hemi- 
plegia, it  is  not  difficult  to  discern  that  the  imperfect  articulation 
and  thick  speech  attending  the  palsy — which,  moreover,  are  very 
apt  to  become  greatly  ameliorated,  or  even  pass  off,  within  a  short 
period  after  the  seizure — are  not  the  cause  of  the  singular  disturb- 
ance of  the  faculty  of  expression  ;  a  disturbance  which  will  mostly 
show  itself  not  simply  by  the  failure  to  utter  words,  but  also  by 
the  inability  to  recollect  them  and  write  them  down.  Indeed,  it  is 
necessary  to  bear  in  mind  that  while  these  states  may  coexist,  they 
also  may  be  present  separately.  Thus,  there  are  persons  who  can 
think,  but  cannot  speak  or  write ;  there  are  those  who  can  think 
and  write,  but  cannot  speak ;  and  there  are  those  who  can  think 
and  speak,  but  cannot  write.  For  the  second  group  the  term 
"aphemia"  has  been  proposed;  for  the  third,  the  term  "agraphia."* 
Most  patients  understand  perfectly  well  what  is  said  to  them ; 
some  can  read  to  themselves ;  and,  unless  the  general  intelligence 

*  Bastian,  Brit,  and  For.  Med.-Chir.  Review,  April,  1869. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  155 

be  perceptibly  affected,  they  can  express  themselves  by  signs  and 
gestures.  In  some  cases  there  is  rather  loss  of  memory,  and  for- 
getfulness  and  confusion,  and  perhaps  a  consequent  use  of  wrong 
words ;  but  when  prompted  the  word  is  at  once  spoken.  Where 
the  power  of  expression  only  is  lost,  but  the  words  are  still  sug- 
gested by  the  memory,  the  term  "ataxic  aphasia"  is  used.  Where 
the  memory  of  words  is  altogether  lost,  it  is  becoming  customary 
to  speak  of  the  affection  as  "  amnesic  aphasia."  Again,  there  are 
cases  in  which  words  and  ideas  remain,  but  in  which  the  power 
of  forming  correct  sentences  is  greatly  impaired.  This  has  been 
named  "akataphasia."* 

Slips  of  the  tongue  are  surely  not  to  be  regarded  as  aphasia,  for 
very  often  these  have  a  local  cause,  such  as  a  sore  tongue  or  lip, 
or  a  sharp  tooth  fretting  the  tongue,  producing  unusual  sensations 
in  the  mouth. f 

Aphasia  is  dependent  upon  disease  situated  in  the  frontal  con- 
volutions, and  by  Broca  the  lesion  is  located  in  the  seat  of  artic- 
ulate language,  in  the  posterior  part  of  the  third  frontal  convolution 
of  the  left  side  of  the  cerebrum.^  This  view  receives  support  from 
the  fact  that  the  hemiplegia  which  may  accompany  aphasia  is 
almost  invariably  right-sided. §  Without  accepting  that  the  dis- 
ease must  be  strictly  in  the  convolution  mentioned, — for  I  have 
myself  met  with  two  cases  in  which  the  part  in  question  was 
healthy, — I  think  it  proved  that  the  mischief  is  usually  there,  or 
certainly  near  it,  in  the  left  anterior  portion  of  the  brain.  It  has 
further  been  shown  that  the  disturbance  will  be  in  the  cortical 
substance  or  in  the  conducting  fibres,  according  to  the  form  of 
aphasia.    Where  the  memory  of  words  is  gone,  it  is  in  the  former. 

*  Steinthal ;  also  Kiissmaul,  in  Ziemssen's  Cyclopaedia. 

f  Ord,  St.  Thomas's  Hospital  Reports,  vol.  iv. 

X  For  ready  use  in  the  study  of  the  convolutions,  I  refer  to  Turner  on  the 
Convolutions  of  the  Human  Cerebrum,  Edinburgh,  1866  ;  or  to  Ecker's  Essay, 
trans.,  New  York,  1873,  and  to  Charcot's  Lectures  on  Localization,  trans., 
New  York,  1878. 

\  Trousseau,  in  his  Clinique  Medicale,  records  an  exception  ;  and  several 
are  mentioned  by  Sanders,  in  the  Edinburgh  Medical  Journal,  June,  1866, 
and  by  Hughlings  Jackson,  in  a  very  interesting  paper  in  the  London  Hos- 
pital Reports,  vol.  i.  Embolism  of  the  cerebral  arteries,  particularly  plug- 
ging of  the  middle  cerebral  artery  on  the  left  side,  is  prone  to  be  the  cause  in 
cases  which  are  associated  with  valvular  disease  of  the  heart  and  which  have 
come  on  suddenly. 


156  MEDICAL    DIAGNOSIS. 

As  regards  the  exact  lesion,  it  is  very  various.  In  cases  of 
aphasia  of  short  duration  and  without  palsy,  there  is  probably 
merely  congestion  ;  in  protracted  cases,  and  those  in  which  we  find 
coexisting  hemiplegia,  a  clot  or  softening  is  likely  to  be  present; 
deficient  tone  of  the  blood-vessels  and  enfeebled  nutrition  will 
perhaps  explain  the  aphasia  which  may  be  noticed  during  the 
convalescence  from  grave  acute  maladies.  This  form  of  the  com- 
plaint and  that  consequent  upon  congestions  end  in  more  or  less 
rapid  and  generally  perfect  recovery ;  in  the  other  forms,  either 
no  improvement  follows,  or  only  a  very  partial  gain  of  words  takes 
place.  Occasionally  we  meet  with  aphasia  in  hysteria,  or  we  en- 
counter aphasia  intimately  connected  with  a  syphilitic  cachexia.* 

The  suddenness  with  which  the  attack  may  set  in  will  cause  it 
to  be  mistaken  for  an  ordinary  apoplectic  seizure.  But  we  may 
find  not  the  least  deficiency  in  motion  in  any  part  of  the  body, 
and  well-preserved  consciousness;  or  the  disease  may  become 
manifest  subsequent  to  attacks  of  vertigo,  or  to  a  paralytic  stroke 
preceded  or  not  by  the  ordinary  signs  of  an  apoplectic  fit.  Under 
these  circumstances  the  diagnosis  cannot  be  definitely  made  until, 
after  fully-returned  consciousness,  we  have  an  opportunity  of  ex- 
amining the  state  of  the  mind,  and  of  the  tongue  and  the  muscles 
concerned  in  articulation,  remembering  that  if  there  be  merely 
difficulty  in  articulation  the  case  is  not  one  of  aphasia. 

In  examining  into  a  case  of  aphasia,  we  must  not  forget  that 
this  is,  after  all,  merely  a  symptom, — nay,  a  symptom  which  may 
follow  an  apoplectic  stroke.  That  it  has  been  here  viewed  as  a 
separate  disorder,  was  simply  as  a  matter  of  clinical  convenience. 

Sun-stroke. — Persons  exposed  to  the  scorching  rays  of  the 
sun  in  midsummer  often  become  dizzy,  and  fall  to  the  ground 
insensible :  they  have  had  a  sun-stroke.  The  attack  either  takes 
place  while  the  patient  is  still  exposed  to  the  sun ;  or,  in  rarer 
instances,  he  reaches  his  home  with  a  staggering  gait,  giddy,  faint, 
suffering  from  a  dull,  oppressive  pain  in  the  head,  and  after  some 
hours  becomes  unconscious.  However  the  onset,  the  insensibility 
which  occurs  is  generally  complete,  although  it  may  be  so  but  for 
a  few  minutes.  Associated  with  it  are  a  frequent  pulse,  a  skin 
harsh  and  warm  and  sometimes  very  hot  on  the  forehead,  ster- 

*  See  Clin.  Soc.  Trans.,  vol.  iii.,  and  Arch.  Gen.  de  Med.,  Feb.  1871. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  157 

torous  breathing,  difficulty  in  swallowing,  and  relaxation  of  the 
limbs.  Scanty  urine,  delirium,  and  convulsions,  which  may  or 
may  not  depend  on  uraemia,  are  not  uncommon. 

When  we  contrast  these  symptoms  with  those  of  apoplexy,  we 
find  the  following  marks  of  distinction :  the  pulse  is  not  slow 
and  full,  but  frequent  and  often  feeble,  or  only  moderately 
strong;  there  is  more  difficulty  in  deglutition,  but  a  less  snoring 
respiration ;  the  coma  does  not  ordinarily  remain  as  complete  for 
so  great  a  length  of  time,  for  soon  the  patient  may,  temporarily 
at  least,  be  partially  roused  from  his  deep  sleep ;  and  no  paralysis, 
either  of  the  limbs  or  of  the  cheek,  occurs.  The  temperature  of 
the  body  is  usually  very  high,  104°  to  109°,  and  not  below  the 
normal,  as  it  is  at  first  in  apoplexy.  The  after-symptoms,  too, 
are  different :  in  cerebral  hemorrhage,  paralysis ;  in  sun-stroke, 
feebleness  of  movement,  but  no  paralysis.  In  the  former,  no 
marked,  persistent  headache ;  in  the  latter,  headache,  more  or  less 
chronic,  always  aggravated  by  walking  in  the  sun,  and  often  for 
months  accompanied  by  signs  of  an  exhausted  nervous  system, 
and  in  some  instances  by  epileptic  convulsions. 

The  question  with  regard  to  the  discrimination  of  these  morbid 
states  is  one  of  great  practical  value,  as  on  the  conclusion  arrived 
at  depends  our  therapeutic  action  ;  and  generally  it  is  readily  de- 
termined by  paying  attention  to  the  variance  in  the  symptoms 
mentioned.  But  it  must  be  confessed  that  we  sometimes  meet 
with  ambiguous  cases, — cases  in  which  the  signs  of  nervous  ex- 
haustion produced  by  exposure  to  heat  are  blended  with  those  of 
cerebral  congestion  or  hemorrhage  excited  by  the  same  cause,  and 
in  which,  when  they  terminate  fatally,  the  autopsy  shows  not 
simply  a  changed  blood,  or  pulmonary  congestion,  but  turgescence 
of  the  cerebral  vessels,  or  an  extravasation.  The  management  of 
such  patients  requires  great  care;  we  must  bleed  or  not,  or  stimu- 
late or  not,  according  to  the  indication  to  which  the  weight  of  the 
symptoms  inclines. 

The  remarks  just  made  refer  to  the  most  common  form  of  sun- 
stroke,— that  attended  with  more  or  less  sudden  loss  of  conscious- 
ness, and  therefore  simulating  apoplexy.  But  there  are  cases  in 
which  the  abnormal  manifestations  come  on  gradually,  and  in 
which  the  patient  at  no  time  becomes  insensible.  I  have  seen  a 
number  of  the  kind :  they  were  not  unusual  among  officers  sent 


158  MEDICAL    DIAGNOSIS. 

home  from  the  wearing  summer  campaigns  of  the  late  war.  The 
chief  symptoms  are  intense  headache,  nausea,  prostration,  and 
inability  to  perform  any  work  requiring  sustained  attention.  All 
these  signs  appear  after  protracted  exposure  to  the  sun  ;  and  they 
mend  but  very  tardily.  In  truth,  in  the  slowly-developed  dis- 
order the  subsequent  nervous  exhaustion  and  the  paroxysms  of 
headache  seem  to  be  much  more  persistent  than  the  same  phe- 
nomena following  what  looks  like  the  more  violent  form  of  the 
malady.  Among  the  sequelae  of  these  apparently  incomplete 
attacks  are  irritability  of  the  bladder,  incontinence  of  urine,  and 
irregular  action  of  the  heart.  But  nothing  is  as  striking  as  the 
loss  of  mental  and  bodily  energy. 

The  symptoms  of  "insolatio,"  or  sun-stroke,  may  be  induced 
by  prolonged  atmospheric  heat,  while  the  patient  is  in-doors  and 
not  exposed  to  the  rays  of  the  sun.  Such  cases  of  heat-stroke  are 
known  to  occur  in  India  even  at  midnight.  They  may  be  pre- 
ceded by  a  sense  of  extreme  weariness,  by  inability  to  sleep,  by  loss 
of  appetite,  by  constipation  and  frequent  micturition,  and  by  de- 
ficient perspiration;  or  the  signs  of  exhaustion,  followed  by  more 
or  less  complete  insensibility,  appear  without  distinct  prodromes. 
Cases  of  the  kind  under  consideration  may  or  may  not  show  an 
increased  or  high  axillary  temperature.     Generally  they  do. 

Then,  again,  we  find  cases  of  heat  exhaustion  in  which  there 
is  great  tendency  to  syncope;  the  skin  is  cool  and  moist,  the  tem- 
perature not  increased,  the  pulse  very  feeble,  and  stimulants  freely 
given  rapidly  relieve  the  urgent  symptoms. 

The  nature  of  heat  exhaustion,  as  of  sun-stroke,  is  obscure.  It 
is  held  by  Dr.  H.  C.  Wood*  to  be  a  fever  not  dependent  upon 
blood-poisoning,  but  upon  heat. 

Catalepsy. — This  is  a  sudden  suspension  of  thought,  of  sen- 
sibility, and  of  voluntary  motion,  during  the  continuance  of  which 
the  muscles  retain  the  exact  position  they  happened  to  be  placed 
in  at  its  onset.  This  uncommon  complaint  occurs  in  paroxysms, 
which  may  last  but  a  few  minutes  or  several  hours,  and  during 
which  the  most  complete  anaesthesia,  not  only  of  the  skin,  but  also 
of  the  deeper  tissues,  may  occur.f  The  disorder  is  met  with  in 
females,  especially  in  hysterical  females,  and  alternates  with  out- 

*  Thermic  Fever,  or  Sunstroke. 

f  As  in  the  case  reported  hy  Lasegue,  Arch.  Gen.  de  Med.,  tome  i.,  1864. 


DISEASES    OF    THE    BEAIX    AXD    SPINAL    COED.  159 

breaks  of  hysteria.  But  it  may  also  exist  in  the  male  sex,  and  be 
in  either  hereditary.  It  has  even  been  noticed  as  an  epidemic  in 
localities  where  there  are  many  families  closely  connected  by  inter- 
marriage.* 

Catalepsy  may  be  mistaken  for  apoplexy,  or  even  for  death.  It 
differs  from  apoplexy  by  its  constant  recurrence:  and,  further, 
during  an  attack  the  eyes  are  wide  open,  the  pupils,  although 
dilated,  are  very  susceptible  to  light;  and  there  is  an. absence  of 
stertorous  breathing  as  well  as  of  the  characteristic  relaxation  of 
the  muscles  or  of  the  paralysis  of  apoplexy, — for  the  limbs  are 
outstretched,  or  held  in  every  conceivable  annoying  or  painful 
position,  yet  as  soon  as  consciousness  is  restored,  their  movement 
fully  returns.  The  pulse  is  not  retarded ;  on  the  contrary,  although 
feeble,  it  becomes  very  frequent. 

The  perplexing  affection  varies  from  a  kindred  state,  ecstasy,  in 
this :  in  the  latter  the  loss  of  consciousness  is  not  complete.  The 
patient  is  merely  insensible  to  external  objects,  because  he  is  in- 
tensely absorbed  in  some  vision  present  to  his  imagination,  or  in 
the  contemplation  of  some  subject  to  him  of  all-engrossing  interest. 
But  he  is  not  statue-like;  on  the  contrary,  his  countenance  is  ani- 
mated and  earnest,  and  he  talks,  declaims,  sings. 

There  is  a  curious  form  of  the  disorder,  which  Sir  Thomas 
vVatson  describes.  It  is  an  imperfect  kind  of  catalepsy,  called 
daymare,  the  affected  person  being  at  the  time  incapable  of  moving 
or  speaking,  yet  cognizant  of  all  that  goes  on.  These  seizures  of 
temporary  deprivation  of  muscular  power,  without  unconscious- 
ness, were  thought,  by  the  accomplished  physician  quoted,  to  have 
depended,  in  the  case  he  cites,  upon  a  diseased  state  of  the  blood- 
vessels of  the  brain.  Were  this  condition  always  present  in  the 
complaint,  it  would  be  a  far  more  serious  one  than  ordinary 
catalepsy. 

Diseases  marked  by  Convulsions  or  Spasms, 

Epilepsy. — Epilepsy  is  a  disease  the  chief  manifestation  of 

which  consists  in  recurring  attacks  of  sudden  loss  of  consciousness, 

attended  with  convulsive   movements.     The  patient  falls  to  the 

ground,  without  thought,  without  feeling,  without  the  power  of 

*  Vogt.  Schmidt's  Jahrbiiclier,  Bd.  cxx.  p.  801. 


160  MEDICAL    DIAGNOSIS. 

voluntary  motion.  He  utters  often  a  short  piercing  cry,  then  a 
fearful  struggle  begins.  The  legs  are  stiff,  and  turned  inward; 
the  head  is  tossed  backward,  or  from  side  to  side;  the  mouth  is 
distorted,  the  lips  are  covered  with  foam;  the  arms  are  out- 
stretched and  rigid,  or  thrown  about  with  great  force;  the  eyelids 
are  half  closed;  the  teeth  are  ground  together,  and  the  tongue  is 
thrust  between  them,  and  often  severely  bitten.  Gradually  the 
convulsive  movements  become  less  violent  and  cease  altogether, 
and  the  patient  passes  into  a  deep  sleep,  from  which-  he  awakes 
fatigued  and  exhausted,  and  dull  in  intellect.  But  these  symp- 
toms disappear,  and  he  returns  to  his  usual  state  of  health. 

Yet  every  paroxysm  does  not  present  the  same  phenomena,  or 
run  the  same  definite  course.  In  many  the  attack  is  preceded  by 
strange  sensations:  by  a  peculiar  train  of  thought;  by  retching; 
by  the  feeling  of  a  puff  of  air  ascending  from  the  extremities  to 
the  head.  This  "  aura  epileptica,"  on  which  so  much  stress  has 
been  laid,  is,  however,  far  from  constant.  But  it  may  exist,  as 
Brown-Sequard  teaches,  without  hardly  being  perceived  :  it  may 
be  an  unfelt  irritation  starting  from  some  centripetal  nerve  in  any 
part  of  the  skin,  or  from  some  organ  not  deeply  seated,  as  the 
testicle,  and  its  point  of  departure  may  be  detected  by  observing, 
during  the  fit,  in  what  neighborhood  the  first,  or  the  most  violent, 
or  the  most  prolonged  contractions  occur.  In  very  rare  instances 
sudden  spasms  of  the  face  and  chest  occur  with  arrest  of  respira- 
tion, and  with  a  subsequent  clonic  convulsion,  yet  with  so  little 
unconsciousness  that  it  remains  doubtful  whether  the  paroxysm 
have  been  attended  at  all  with  unconsciousness. 

Some  seizures  are  very  light, — a  transient  suspension  of  con- 
sciousness, a  slight  twitching  of  some  of  the  muscles,  a  fixed  gaze, 
perhaps  a  decided  impression  of  vertigo,  and  all  is  over.  These 
abortive  fits,  the  petit  mat  of  the  French,  are  very  apt  to  precede 
by  some  days  a  severe  attack,  or  several  of  them  may  take  the 
place  of  the  more  turbulent  form  of  the  disorder.  And  they,  too, 
like  the  graver  epileptic  convulsion,  may  present  strange  irregu- 
larities. They  may  manifest  themselves,  for  instance,  only  in 
bursts  of  unmeaning  laughter;*  or  intellectual  derangement  re- 
places the  ordinary  convulsive  attack.f 

*  George  Paget.  British  Medical  Journal,  Feb.  1859. 

f  Thorne  on  Masked  Epilepsy,  St.  Bartholomew's  Hosp.  Rep.,  vol.  vi. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  161 

The  epileptic  paroxysm  does  not  always  pass  off  without  leaving 
some  trace  of  the  profound  disturbance  it  has  occasioned.  It  may 
be  followed  by  hemiplegia,  due,  it  is  ordinarily  thought,  to  a 
congestion  of  the  brain  during  the  fit.  Whether  this  be  the 
explanation  or  not,  or  whether,  as  Hughlings  Jackson*  teaches, 
the  hemiplegia  be  due  to  exhaustion  of  the  nerve-tissue  following 
the  excessive  discharge  signified  by  the  convulsion,  it  is  certain 
that  the  palsy,  like  that  following  cerebral  congestion,  is  very  tran- 
sient and  generally  disappears  in  a  few  days.  Another  sequel  of 
the  attack  is  aphasia ;  another,  loss  of  voice ;  another,  abdominal 
tenderness. 

In  the  intervals  between  the  seizures  the  patient  is  not  in  reality 
well.  His  temper  is  irritable,  and  his  mental  faculties  slowly  but 
certainly  deteriorate.  The  loss  of  memory,  particularly,  is  very 
marked ;  and  dementia  is  not  an  unusual  complication  of  long- 
continued  epilepsy.  In  some  epileptics,  as  Herpin  so  well  points 
out,  there  is  much  mental  excitement  or  a  curious  mental  state 
preceding  the  seizures,  or  a  violent  and  dangerous  mania  following 
the  fit.f  Again,  as  I  have  had  occasion  to  note  in  common  with 
several  recent  observers,  a  temporary  albuminuria  is  not  unfre- 
quently  met  with  at  the  termination  of  the  paroxysm. 

Epilepsy  is  either  central  or  peripheral :  that  is,  the  exciting 
cause  is  seated  in  the  nervous  centres,  especially  in  the  brain  or 
medulla;  or  affects  the  centripetal  nerves,  and  is  by  them  reflected 
to  the  nervous  centres.  It  is  thus  that  the  malady  originates  in 
injuries  of  nerves,  in  diseases  of  the  skin,  of  the  gastro-intestinal 
tract,  or  of  the  uterus,  in  the  irritation  of  worms,  or  in  conse- 
quence of  congenital  phimosis.^  Now,  with  reference  to  both 
the  prognosis  and  the  treatment,  it  is  very  important  to  discrimi- 
nate between  epilepsy  of  centric  and  epilepsy  of  eccentric  origin  ; 
and  to  arrive  at  this  discrimination  is  possible  only  by  a  thorough 
examination  of  all  the  constitutional  symptoms,  and  by  ascertaining 
the  starting-point  and  tracing  the  course  of  the  aura.  Another 
diagnostic  element  of  great  practical  value  is  to  determine,  after 
we  have  concluded  the  epilej)sy  to  be  central,  if  it  be  symptomatic 
of  a  cerebral  disorder, — such  as  of  a  tumor,  of  cysticerci  lodged 

*  After-Effects  of  Epileptic  Discharges,  "West  Biding  Eeports,  1876. 

f  Maudsley,  article  "Insanity,"  in  Eeynolds's  System  of  Medicine,  vol.  ii. 

%  Althaus,  Lancet,  Eeb.  1867. 

11 


162  MEDICAL    DIAGNOSIS. 

in  the  organ,  of  a  syphilitic  affection  of  the  membranes,  or  of  a 
disturbance  of  the  brain  produced  by  disease  of  the  skull-cap, — in 
fact,  of  any  of  those  cerebral  maladies  which  are  known  to  en- 
gender epileptic  seizures;  or  if  it  be  watery  blood,  or  vitiated 
blood  full  of  abnormal  ingredients,  as  in  diseases  of  the  kidneys, 
acting  injuriously  on  the  nutrition  of  the  cerebral  texture;  or  if 
it  be  idiopathic,  due  to  causes  we  do  not  fully  understand,  chief 
among  which,  perhaps,  if  we  may  look  upon  the  observations  of 
Kiissmaul  and  Tenner  *  and  of  Schroeder  van  der  Ivolk  f  as  con- 
clusive, are  a  morbid  excitation  and  an  affection  of  the  medulla 
oblongata.  During  the  paroxysm  it  is  impossible  to  determine  its 
cause;  but  in  the  interval  we  may  often  do  so  by  close  attention 
to  the  history  of  the  case,  and  by  noting  whether  the  patient  en- 
joys the  usual  health  of  epileptic  subjects,  or  presents  signs  of  a 
chronic  cerebral  trouble.  Romberg  tells  us  that  where  affections 
of  the  bones  lie  at  the  root  of  the  complaint,  the  fits  are  readily 
induced  by  pressure  upon  the  skull ;  and  further,  that  if  there  be 
disease  residing  in  one  of  the  cerebral  hemispheres,  the  aura  affects 
the  opposite  side  of  the  body,  and  is  generally  confined  to  the 
upper  extremity. 

Limited  convulsive  seizures  are  connected  with  disease  of  special 
convolutions ;  and  since  the  admirable  observations  of  Hughlings 
Jackson  |  have  shown  us  the  way,  we  know  that  if  we  have  a  con- 
vulsion which  is  limited,  or  at  least  begins  in  always  the  same 
limited  manner,  we  may  from  this  monospasm  diagnosticate  an 
irritative  lesion  in  the  motor  centre  of  the  opposite  hemisphere 
presiding  over  the  disturbed  part.  The  irritative  lesion  is  most 
frequently  a  meningo-encephalitis;  the  centre  involved  becomes 
highly  charged,  a  discharge  takes  place  with  the  convulsion,  and 
a  temporary  paralysis  in  the  affected  group  of  muscles  results. 
At  first  there  is  no  loss  of  consciousness  during  the  seizure,  but  as 
the  spasms  spread  and  become  unilateral  consciousness  is  lost. 
Syphilitic  epilepsy  is,  for  the  most  part,  of  the  character  just 
described. 

*  On  Epileptiform  Convulsions.  Translated  by  New  Sydenham  Society, 
1859. 

f  Minute  Structure  and  Functions  of  Spinal  Cord  and  Medulla.  Sydenham 
Soc,  1859. 

J  Medical  Times  and  Gazette,  1875. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  163 

Much  has  been  said  of  the  distinction  between  epilepsy  and 
convulsions.  Now,  as  regards  the  seizure  itself,  there  is  no  appre- 
ciable difference ;  the  only  diversity  consists  in  the  recurrence  of 
the  attack  after  intervals  of  comparative  health,  and  in  the  non- 
existence of  any  disturbance  from  which  convulsions  are  likely  to 
arise,  such  as  a  recent  injury  to  the  head,  an  eruptive  fever,  the 
parturient  state,  inflammation  of  the  brain,  a  Bright's  kidney, 
teething,  or  rickets.  In  children,  who,  as  is  well  known,  are 
particularly  subject  to  convulsions,  the  diagnosis  may  be  a  diffi- 
cult matter;  but  the  fits  of  epilepsy  are  distinguishable  by  the 
dulness  of  intellect,  and  the  slow  mental  and  bodily  development, 
observable  in  the  intervals.  And  we  are  not  often  called  upon 
to  make  this  differential  diagnosis,  because  of  the  extreme  rarity 
with  which  epilepsy  occurs  in  the  young;  although  many  insist 
that  it  is  more  frequent  than  is  supposed,  basing  this  assumption 
on  the  generally-received  fact  that  the  history  of  epileptics  shows 
them  to  have  suffered  greatly  from  convulsions  during  childhood. 

The  diseases  which  are  most  apt  to  be  confounded  with  epilepsy 
are  hysteria  and  apoplexy.  The  former — like  all  the  rest  of  the 
group  now  under  discussion,  like  chorea,  like  tetanus,  like  hydro- 
phobia— is  discriminated  by  the  absence  of  that  perfect  suspension 
of  consciousness  that  takes  place  in  epileptic  seizures ;  and  there 
are  other  marks  of  distinction,  to  which  we  shall  presently  refer. 
In  apoplexy,  as  in  epilepsy,  we  meet  with  loss  of  consciousness, 
sometimes  with  convulsions.  But  these  are,  on  the  whole,  rare, 
and  coma  precedes  and  does  not  follow  them,  as  happens  in  epi- 
lepsy. Then,  stertorous  breathing,  and  a  slow,  full  pulse,  are  not 
observed  in  epilepsy;  for  the  breathing,  although  irregular  and 
gasping,  is  not  coarse  and  noisy,  and  the  pulse  is  feeble,  irregular, 
and  frequent.  Epileptic  patients  bite  their  tongue;  this  does  not 
occur  in  apoplexy.  In  epilepsy  the  paroxysm  seldom  lasts  longer 
than  from  ten  to  fifteen  minutes  before  consciousness  returns 
and  before  the  convulsions  cease ;  in  apoplexy  the  insensibility  is 
of  much  longer  duration.  Epilepsy  is  not  usually  followed  by 
paralysis ;  apoplexy  is  commonly. 

Epilepsy  is  often  feigned ;  yet  impostors  cannot  feign  it  com- 
pletely. They  may  bite  their  tongue;  they  may  imitate  the  stertor, 
the  foam  at  the  mouth,  the  convulsions,  the  thumb  drawn  inward 
toward  the  palm,  the  confused  air  on  awakening;  they  may  simu- 


164  MEDICAL    DIAGNOSIS. 

late,  although  they  rarely  do  so,  the  indifference  to  pain;  vet 
there  is  one  feature  of  the  real  attack  they  cannot  copy, — the  in- 
sensibility of  the  iris.  No  matter  how  skilful  the  dissembler,  his 
pupils  must  contract  when  exposed  to  a  strong  light,  they  must 
dilate  when  the  stimulus  is  withdrawn. 

But,  unfortunately,  there  are  several  difficulties  in  making  this 
test  an  absolute  one.  In  the  first  place,  the  pupils,  during  a  fit, 
cannot  always  be  readily  observed.  In  the  second  place,  not  in 
every  case  of  epilepsy  are  they  perfectly  immovable;  in  some, 
though  sluggish,  they  react  to  light.  And  again,  as  proved  by 
Dr.  Keen,  violent  muscular  motion  instantly  dilates  the  pupil, 
and  so  long  as  the  movement  continues,  so  long  will  the  iris  act 
sluggishly,  even  when  exposed  to  a  bright  light.  Thus,  muscular 
spasms  alone,  even  when  simulated,  may  cause  the  pupils  to  be 
dilated  and  inactive.  A  test  said  to  be  more  generally  useful  is 
the  administration  of  ether.  When  given  to  an  epileptic,  its  first 
effect  is  to  increase  the  violence  of  the  spasm,  but  eventually  the 
patient  passes  into  the  deep  sleep  produced  by  ether,  without  any 
of  the  prior  cerebral  excitement;  while  in  the  malingerer  this 
manifests  itself  by  talking  and  laughing, — in  fact,  in  the  usual 
way.* 

Chorea. — This  spasmodic  affection  is  chiefly  met  with  in  young 
persons,  especially  in  girls  approaching  the  age  of  puberty.  It 
is  characterized  by  irregular  clonic  spasms  of  groups  of  muscles 
under  the  influence  of  the  will,  and  mainly  of  those  on  one  side  of 
the  body.  But  the  patient  is  not  deprived  of  consciousness  and 
of  all  power  of  voluntary  motion.  He  knows  what  he  is  about, 
and  can  in  part  execute  the  movements  he  undertakes ;  yet  his 
limbs  are  not  completely  under  his  control.  They  obey  only  his 
general  directions,  but  not  entirely  or  at  once;  for  the  muscles  jerk 
and  pull  as  seems  to  them  best,  taking  no  heed  of  the  time  or  the 
manner  in  which  the  will  wishes  any  movement  executed.  In  some 
cases,  not  in  many,  the  muscles  of  deglutition  and  of  respiration 
become  implicated,  and  difficulty  in  swallowing  and  in  breathing 
occurs.  A  dilated  pupil,  too,  acting  very  sluggishly  in  response 
to  light,  may  be  met  with  among  the  phenomena  of  this  singular 
malady. 

*  Keen,  Mitchell,  and  Morehouse,  Amer.  Journ.  of  Med.  Sci.,  Oct.  1864. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  165 

Chorea  is  essentially  a  functional  disorder  of  the  nervous 
centres;  at  least  morbid  anatomy  has  as  yet  failed  to  prove  its 
definite  connection  with  any  organic  lesion.  In  a  large  number 
of  persons  the  malady  is  called  into  existence  by  an  irritation  of 
peripheral  portions  of  the  nervous  system.  Thus,  a  blow,  a 
wound  of  a  nerve,  disorders  of  the  uterus,  painful  menstruation, 
pregnancy,  or  gastric  or  intestinal  affections  may  act  as  the  ex- 
citing cause  of  the  perverted  muscular  movements.  In  cases  due 
to  organic  causes,  plugging  of  the  vessels  leading  to  the  corpus 
striatum  is  found  to  be  the  most  common  lesion,  a  one-sided 
embolism  giving  rise  to  one-sided  chorea.*  And  the  association 
with  vegetations  on  the  valves  is  in  fatal  cases  certainly  very 
frequent. f  It  has  indeed  been  suggested  that  the  wild,  maniacal 
delirium,  with  subsequent  rapid  emaciation,  which  we  meet  with 
in  some  instances  of  chorea,  has  its  origin  in  embolism.J 

Chorea  may  be  produced  by  strong  mental  emotion,  especially 
by  fright.  It  may  follow  scarlet  fever,  but  it  is  more  often  the 
sequence  of  rheumatic  fever  or  arises  from  the  same  diathesis  that 
attends  or  occasions  rheumatism.  Yet  this  is  not,  as  some  have 
alleged,  its  only  cause ;  for  in  a  number  of  persons  affected  with 
chorea  we  fail  to  detect  any  proof  of  a  rheumatic  diathesis.  And 
as  regards  the  cardiac  complication,  the  presence  of  which  is  chiefly 
deduced  from  the  existence  of  a  murmur,  the  inference  drawn 
from  this  sign  is  hardly  a  fair  one ;  for  is  it  not  often  due  to 
anaemia,  or  dependent  upon  spasmodic  action  of  the  papillary 
muscles, — the  same  spasmodic  action  that  is  seen  in  the  striated 
muscles  of  the  face  or  of  the  extremities? 

The  disease  is  rarely  fatal :  but  it  is  not  of  short  duration  ;  for, 
although  it  may  be  acute,  it  commonly  lasts  for  months.  There 
are  in  chronic  cases  no  cerebral  symptoms  attending  it,  yet  the 
mental  faculties  are  not  in  a  perfectly  healthy  state.  The  intellect 
of  a  choreic  child  develops  slowly,  and  is  evidently  enfeebled 
while  the  disorder  lasts.  In  some  cases  paralysis  supervenes  ;  but 
it  is  not  permanent,  nor,  indeed,  of  long  duration.  But  those  who 
have  been  choreic  remain  subject  to  nervous  disorders ;  and  I  have 

*  Hughlings  Jackson,  London  Hospital  Beports,  vol.  ii.,  and  Edinburgh 
Medical  Journal,  Oct.  1868. 
f  Ogle,  Brit,  and  For.  Med.-Chir.  Bev.,  1868. 
t  Tuckwell,  ibid.,  Oct.  1867. 


166  MEDICAL    DIAGNOSIS. 

known  several  instances  in  which  the  complaint  has  been,  in  after- 
years,  followed  by  epilepsy. 

The  diagnosis  of  chorea  is  generally  easy.  The  malady  differs 
from  the  spasms  of  acute  cerebral  disease  by  the  absence  of  fever, 
of  delirium,  and  of  coma;  from  epilepsy,  by  its  being  continuous, 
by  the  non-existence  of  unconsciousness,  and  by  the  rarity  with 
which  the  muscles  jerk  at  a  time  when  epileptic  convulsions  are 
most  frequent,  namely,  at  night;  from  tetanus  it  is  chiefly  dis- 
tinguished by  not  exhibiting  tonic  spasms. 

Paralysis  agitans  is,  like  chorea,  attended  with  disturbed  mus- 
cular movements.  But  we  find  weakness  of  the  muscles  and 
persistent  tremor  rather  than  spasmodic  contraction  and  want  of 
control  over  muscular  motion.  Then  the  history  of  the  case, 
showing  its  frequent  origin  in  prolonged  exposure  to  moist  cold, 
and  the  signs  of  general  decav  associated  with  the  trembling;, 
clearly  distinguish  paralysis  agitans.  In  the  organic  form  of 
shaking  palsy  we  have  the  symptoms  characteristic  of  cerebro- 
spinal sclerosis,  and  the  peculiar  stolid  countenance,  the  jerks  only 
when  the  muscles  are  put  into  motion,  and,  unlike  the  abrupt  and 
erratic  movements  of  chorea,  a  persistence  in  the  direction  given 
to  the  motion  notwithstanding  the  oscillations,  are  most  significant. 
Both  affections,  too,  are  encountered  chiefly  in  persons  older  than 
are  subject  to  chorea;  especially  is  paralysis  agitans.  We  meet, 
however,  with  cases  of  paralysis  agitans  nearly  affiliated  to  chorea ; 
like  it,  too,  originating  in  fright.  But  they  differ  in  the  motions 
repeating  themselves  rhythmically  and  symmetrically  on  the  two 
sides  of  the  body,*  and  in  presenting  nothing  of  the  irregular  and 
rapidly  changing  character  of  the  true  choreic  movements. 

Convulsive  tremor,  to  adopt  the  name  given  by  Hammond  to  a 
paroxysmal  affection  in  which  severe  muscular  tremor  arises  several 
times  in  the  day,  differs  from  chorea  in  not  being  continuous, 
as  it  occurs  in  attacks  lasting  from  fifteen  to  twenty  minutes, 
passing  off  gradually,  and  leaving  the  patient  in  a  profuse  per- 
spiration. The  seizures,  moreover,  in  their  sudden  onset  resemble 
more  an  attack  of  epilepsy,  and  there  is  slight  headache,  with 
vertigo,  and  an  intense  feeling  of  anxiety,  without,  however,  un- 
consciousness.   The  unrestrainable  tremor  affects  the  face,  the  arms, 

As  in  the  case  recorded  by  Sanders,  Edin.  Med.  Journ.,  May,  1865. 


DISEASES    OF    THE    BRAIX    AXD    SPIXAL    CORD.  167 

and  the  trunk,  but  not  the  lower  extremities,  and  is  associated 
with  increased  sensibility  of  the  skin  of  the  disturbed  parts. 

Mercurial  tremor,  another  variety  of  tremor,  is  discriminated 
from  chorea  by  observing  that  the  trembling  and  the  incessant 
movements  stop  when  the  shaking  limb  is  supported.  And  the 
gradual  manner  in  which  the  disease  appears,  its  occurrence  among 
persons  whose  occupations  predispose  them  to  the  absorption  of 
mercury,  the  wakefulness,  the  disorder  of  the  digestive  organs, 
and  the  sponginess  of  the  gums, — form  a  group  of  phenomena 
very  dissimilar  to  those  of  chorea. 

In  athetosis,  the  disease  described  by  Hammond,  there  is  con- 
tinual motion  of  the  fingers  and  toes  and  inability  to  retain  them 
in  any  position  in  which  they  may  have  been  placed.  Great  ten- 
dency to  distortion  exists,  and  we  find,  on  the  whole,  much  re- 
semblance to  localized  chorea.  But  the  malady  generally  comes 
on  with  epileptic  paroxysms ;  and  headache,  vertigo,  slowness  of 
speech  and  of  thought,  tremulousness  of  the  tongue,  numbness 
of  the  affected  side, — for  the  disorder  is,  for  the  most  part, 
unilateral, — and  jDains  in  the  limbs  which  are  the  seat  of  the 
spasms,  give  us  a  very  different  clinical  picture  from  chorea. 

Facial  spasm  differs  from  the  spasmodic  contractions  of  chorea 
in  being  always  of  equal  intensity,  and  in  the  grimaces  being 
strictly  confined  to  the  same  group  of  muscles,  and  generally 
existing  only  on  one  side  of  the  face. 

The  writer's  cramp,  an  affection  in  which  every  attempt  at 
writing  at  once  produces  spasmodic  action  of  the  muscles  of  those 
fingers  which  are  brought  into  play,  is  separated  from  chorea  by 
its  occurrence  in  individuals  who  have  strained  their  muscles  in 
using  a  pen  continuously  and  rapidly  ;  by  the  almost  instant  ces- 
sation of  the  spasm  when  the  afflicted  person  ceases  to  write ; 
and  by  the  ease  with  which  the  fingers  perform  other  motions  and 
are  capable  of  being  used  for  every  other  purpose  except  the  one 
which  has  brought  on  the  disorder.  A  very  analogous  complaint 
is  sometimes  encountered  in  seamstresses ;  and,  as  has  been  recently 
shown,  also  in  telegraph-operators,  particularly  those  who  use  the 
Morse  instrument.  These  cramps,  and  all  those  of  a  similar  kind 
caused  by  the  occupation,  such  as  in  piano-players  and  in  violin- 
ists, have  the  same  diagnostic  sign  that  has  just  been  mentioned  as 
characteristic  of  writer's  cramp, — namely,  that  the  spasm  befalls 


168  MEDICAL    DIAGNOSIS. 

only  those  muscles  the  overstrain  of  which  has  led  to  the  affec- 
tion, and  that  it  ceases  when  the  fatigued  muscles  are  kept  at  rest 
or  are  brought  into  action  for  a  different  purpose. 

There  is  a  disorder,  closely  allied  to  chorea,  which  consists  in 
repeated  violent  bobbings  of  the  head,  lasting  many  minutes  at 
a  time.  These  salaam  convulsions,  as  Sir  Charles  Clarke  calls 
them,  are  a  very  obstinate  complaint.  They  are  most  commonly 
met  with  in  children,  but  have  been  known  to  occur  in  adults*  and 
to  lead  frequently  to  impairment  of  the  intellect.f 

Hysteria. — This  description  of  hysteria  will  deal  chiefly  with 
the  symptoms  of  an  hysterical  paroxysm.  Most  of  the  local  hys- 
terical affections  have  been,  or  will  be,  considered  in  connection 
with  the  diseases  they  ape ;  and  to  discuss  any  questions  relating 
to  the  nature  of  this  perplexing  malady,  or  to  attempt  to  scruti- 
nize or  to  interpret  all  the  false  and  contradictory  signals  it  hangs 
out,  is,  in  a  work  of  this  kind,  manifestly  impossible. 

An  hysterical  fit  may  set  in  suddenly,  under  the  influence  of 
some  violent  mental  emotion ;  but  more  generally  it  is  preceded 
by  altered  spirits,  by  a  sensation  of  pressure,  and  of  constriction 
at  the  pit  of  the  stomach,  which  feeling  ascends  to  the  throat,  and 
is  likened  by  the  patient  to  the  rising  of  a  ball.  She  becomes 
much  agitated,  sobs,  laughs,  cries,  her  muscles  contract  violently, 
or  she  lies  motionless,  and  apparently  without  the  power  of  mo- 
tion, until  her  seeming  insensibility  is  disturbed  by  something  she 
disapproves  of,  or  fears.  The  heart  palpitates;  the  breathing  is 
irregular  and  heaving, — on  account,  perhaps,  of  an  affection  of 
the  larynx,  but  not  of  its  temporary  closure,  which,  as  Marshall 
Hall  tells  us,  so  commonly  ensues  in  epilepsy. 

These  hysterical  outbursts  differ  from  the  spasms  of  chorea  by 
their  remissions,  the  patient  remaining  at  times  for  months  free 
from  the  convulsive  movements.  Moreover,  there  is  not  even 
partial  unconsciousness  in  chorea.  It  is  true  that  this  malady 
and  hysteria  are  sometimes  combined,  or  rather  that  chorea  hap- 
pens in  hysterical  subjects ;  yet,  even  then,  it  is  remarkable  how 
rarely  fits  of  hysteria  take  place  in  those  affected  with  chorea. 

It  is  sometimes  very  difficult  to  distinguish  between  paroxysms 
of  hysteria  and  of  epilepsy ;  and  it  becomes  the  more  difficult  if 

*  Levick,  Amer.  Journ.  of  Med.  Sciences,  Jan.  1862. 

f  Henry  Barnes,  Liverpool  and  Manchester  Hospital  Keports,  1873. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD. 


169 


the  epileptic  seizures  occur  in  hysterical  patients.  Yet  there  are 
ordinarily  many  well-marked  points  of  distinction  between  the 
two  maladies,  as  will  be  seen  from  this  table : 


Hysteria. 

Gradual  and  only  partial  or  apparent 

unconsciousness. 
Face  flushed,  or  complexion  unaltered  ; 

no   froth  on  lips ;    eyelids   closed ; 

eyeballs  fixed ;  neither  grinding  of 

the  teeth  nor  biting  of  the  tongue  ; 

pupils  react  readily. 

No  distortion  of  countenance. 
Patient  sighs,  or  laughs,  or  sobs. 
Globus  hystericus. 
No  such  difference ;  convulsions  clonic. 


Epilepsy. 

Sudden  and  complete  loss  of  conscious- 
ness. 

Livid  face ;  escape  of  frothy  saliva 
from  the  mouth ;  eyelids  half  open  ; 
eyeballs  rolling ;  grinding  of  the 
teeth  ;  biting  of  the  tongue ;  more 
or  less  insensibility  of  the  pupils  to 
light. 

Distortion  of  countenance. 

Patient  evinces  no  feeling. 

Aura  epileptica. 

Convulsions  often  more  marked  on 
one  side  than  on  the  other;  and 
more  tonic  than  clonic. 

Paroxysm  generally  of  short  dura- 
tion. 

Paroxysm  followed  by  a  heavy,  half- 
comatose  sleep,  by  headache,  and 
by  dulness  of  intellect. 

Frequently  occurs  at  night. 
No  particular  connection  with  uterine 
.disturbance,  although  a  paroxysm 

often  takes  place  at  the  menstrual 

period. 

There  are,  however,  spasms  that  occur  in  hysterical  patients 
which,  though  a  functional  nervous  affection,  appear  like  a  blend- 
ing of  hysteria  and  epilepsy.  Charcot*  particularly  has  recently 
called  attention  to  this  hystero-epilepsy,  and  describes  its  distinctive 
traits  as  consisting  in  premonitory  symptoms  of  rather  long  dura- 
tion, and  exhibiting  an  aura  which,  starting  in  most  cases  from  the 
ovarian  region,  advances  progressively  to  the  head.  The  cry  is  pro- 
longed and  modulated,  not  short  like  the  epileptic  cry.  The  con- 
vulsions are  identical ;  but,  instead  of  entering  subsequently  upon 
a  stage  of  snoring,  the  hystero-epileptic  sobs,  laughs,  gesticulates 
violently,  or  is  delirious  and  subject  to  hallucinations.  In  the 
ovarian  form  of  hystero-epilepsy,  pressure  upon  the  ovary  will  in- 


Paroxysm  generally  of  longer  dura- 
tion. 

Paroxysm  not  followed  specially  by 
sleep ;  patient  often,  after  attack 
terminates,  wakeful  and  depressed 
in  spirits. 

Rarely  occurs  at  night. 

Often  connected  with  disorders  of  the 
uterus,  or  of  menstruation. 


*  Lectures  on  Diseases  of  the  Nervous  System,  collected  by  Bourneville. 


170  MEDICAL    DIAGNOSIS. 

variably  modify  the  symptoms,  if  not  completely  arrest  the  attack; 
whereas  in  epilepsy  no  such  effect  is  produced.  In  the  cases  of 
hystero-epilepsy  with  repeated  attacks,  the  temperature  scarcely 
rises  above  the  normal,  as  it  rapidly  does  under  similar  circum- 
stances in  epilepsy.  There  is  no  epileptic  vertigo;  there  are  no 
abortive  fits. 

Hysteria  is  not  an  affection  merely  of  paroxysms.  In  the  in- 
tervals between  them  we  find  peculiar  and  significant  manifesta- 
tions of  the  strange  complaint,  which  should  be  understood  lest 
they  be  taken  as  the  signs  of  other  troubles.  We  observe  an 
extreme  susceptibility  of  the  nervous  system,  various  hyperes- 
thesia?, such  as  tenderness  in  the  epigastrium  or  in  the  course  of 
the  spinal  column  or  over  the  ovary;  that  peculiar  pain  in  the 
left  side  which  distresses  so  many  hysterical  and  ansemic  women  ; 
and  sometimes  local  anaesthesia.  Besides  these,  we  encounter 
manifold  local  hysterical  ailments,  such  as  hysterical  paralysis, 
hysterical  aphonia,  hysterical  peritonitis,  hysterical  affections  of 
joints,  hysterical  pain  in  the  forehead,  hysterical  suppression  as 
well  as  hysterical  retention  of  urine. 

The  distinction  between  these  hysterical  pseudo-maladies  and 
the  diseases  they  simulate  is  far  from  being  an  easy  task.  We 
have  to  take  into  account  the  patient's  age  and  sex ;  the  existence 
of  any  irregularity  in  the  uterine  functions;  whether  or  not  she 
has  suffered  from  paroxysms  of  hysteria;  how  the  pain  is  influ- 
enced by  pressure;  and  the  signs  of  functional  disorder  of  the 
apparently  affected  part.  We  may  thus  avoid  mistaking  a  phan- 
tom for  a  true  disease.  Yet  there  is  another  and  opposite  source 
of  error  quite  as  strenuously  to  be  guarded  against.  The  com- 
plaint may  be  really  an  organic  one,  occurring  in  an  hysterical 
patient,  and  concealed,  or  exaggerated  and  complicated,  by  the 
symptoms  of  hysteria.  In  all  such  doubtful  cases  we  must  accord 
great  weight  to  the  extent  of  functional  and  constitutional  dis- 
turbance accompanying  the  local  morbid  state.  Then,  too,  hys- 
terical symptoms  may  be  prominent  in  certain  brain  affections.  I 
have  repeatedly  noticed  them  in  cases  of  cerebral  embolism;  and 
Brown-Sequard  and  Seguin*  have  shown  their  frequent  occur- 
rence in  lesions  of  the  right  hemisphere. 

*  Archives  of  Electrology  and  Neurology.  May.  1875. 


DISEASES    OE    THE    BRAIN    AND    SPLSAL,    CORD.  171 

Hysteria  is  sometimes  feigned, — feigned  to  elicit  sympathy,  or 
to  procure  compliance  with  wishes  or  caprices.  Xor  is  the  simu- 
lation of  the  disorder  an  outgrowth  from  our  civilization.  The 
epigrams  of  Martial  prove  how  common  the  feigning  of  hysteria 
was  among  the  Roman  women. 

Tetanus. — A  disease  of  obscure  pathology,  but  of  clearly 
defined  and  thoroughly  characteristic  symptoms,  marked  by  per- 
sistent rigid  contraction  of  the  voluntary  muscles,  particularly  of 
those  of  the  jaw. 

This  distressing  malady,  as  we  see  it,  is  generally  traumatic, 
following  a  wound  or  an  injury ;  for  idiopathic  tetanus  is  very 
seldom  met  with  in  temperate  climates.  But  in  hot  countries,  or 
in  those  in  which  sudden  alternations  of  temperature  are  common, 
it  is  not  a  rare  disease,  and  is  indeed  frequent  among  children. 
The  cases  of  idiopathic  tetanus  we  encounter  are  almost  always  the 
result  of  exposure  to  cold. 

The  muscles  ordinarily  first  affected  are  those  of  the  jaw  and 
neck;  there  is  a  stiffness  about  them  which  the  patient  is  apt  to 
attribute  to  having  caught  cold.  Sometimes,  however,  the  dis- 
order exhibits  itself  primarily  in  the  external  respiratory  muscles. 
When  the  malady  is  fully  developed,  most  of  the  muscles  are  stiff 
and  hard,  the  jaw  cannot  be  opened, — whence  the  common  name 
of  lock-jaw, — and  there  is  much  difficulty  in  speaking  and  in 
swallowing.  With  these  symptoms  we  usually  find  rigidity  of 
the  muscles  of  the  abdomen  and  of  the  limbs,  and  a  distressing 
pain  at  the  pit  of  the  stomach,  dependent  upon  spasms  of  the 
diaphragm.  Besides  the  permanent  contraction  of  the  voluntary 
fibres,  exacerbations  of  spasm  take  place,  during  which  the  muscles 
become  very  hard.  These  paroxysms  are  accompanied  by  intense 
pain,  and  recur  with  increased  severity  and  frequency  as  the  dis- 
ease advances  to  a  fatal  termination.  When  at  their  height,  the 
body  becomes  curved,  the  patient  merely  resting  upon  his  head 
and.  heels.  This  is  opisthotonos;  while  the  setting  of  the  jaw, 
especially  when  its  muscles  alone  are  affected,  is  called  trismus. 

Notwithstanding  the  striking  muscular  disorder  and  the  ex- 
hausting pain,  there  is  little  constitutional  disturbance ;  the  pulse 
may  be  quickened,  but  it  preserves  its  volume  until  the  last  stage 
is  reached ;  and  there  is  no  perceptible  fever,  nor  is  the  intellect 
affected.     But  the   temperature   shows  extraordinary  variations. 


]72  MEDICAL    DIAGNOSIS. 

It  is  unusually  high,  and  the  thermometer  marks  an  increase  of 
several  degrees  in  the  evening.* 

Tetanus  runs  an  acute  or  a  chronic  course.  Some  cases  last 
three  weeks,  and  when  of  such  long  duration  are  apt  to  recover. 
But  generally  the  malady  terminates  fatally  before  the  eighth 
day. 

Few  complaints  are  likely  to  be  confounded  with  tetanus;  yet 
these  few  resemble  it  closely  in  many  respects.  For  instance,  one 
of  the  freaks  of  hysteria  is  to  take  the  appearance  of  tetanus;  and 
tonic  spasms  dependent  upon  an  affection  of  the  spinal  cord  or 
medulla  oblongata,  strychnia  poisoning,  or  hydrophobia,  may  ac- 
curately simulate  its  symptoms. 

Hysterical  tetanus  is  distinguished  from  the  real  disease  by  being 
preceded  by,  or  attended  with,  fits  of  hysteria;  by  the  age  and  sex 
of  the  patient ;  by  the  absence  of  pain ;  by  the  occasional  occur- 
rence of  clonic  instead  of  tonic  spasms;  and  by  the  intermission 
every  now  and  then  of  all  muscular  rigidity.  Moreover,  the  in- 
fluence of  the  mind  upon  the  seeming  tetanus  is  very  striking.  If 
within  hearing  of  the  patient  the  employment  of  cold  to  the  spine, 
or  of  the  cautery,  be  threatened,  or,  better  still,  if  the  latter  in- 
strument be  actually  made  ready  for  use  before  her,  an  extraor- 
dinary subsidence  of  all  stiffening  and  starting  of  the  limbs  takes 
place. 

Tetanic  spasms  symptomatic  of  an  affection  of  the  spinal  cord 
are  separated  from  tetanus  by  the  different  history ;  by  no  violent 
exacerbations  being  brought  on,  as  they  are  in  tetanus,  by  slight 
movements,  or  by  an  attempt  at  speaking,  or  by  any  reflex  irrita- 
tion ;  by  the  absence  of  marked  remissions ;  by  the  rigidity  being 
almost  always  limited  to  the  extremities  —  except  in  the  case 
of  meningeal  apoplexy  in  the  cervical  region,  in  which  the  tonic 
contraction  in  the  upper  extremity  is  associated  with  stiffness 
of  the  neck;  and  by  the  setting  in  of  palsy  before  the  malady 
terminates. 

In  the  tetanic  spasms  which  may  occur  in  scarlet  fever,  in 
typhus,  in  smallpox,  or  in  pyaemia,  and  which  are  the  result  of  an 
irritation  of  the  cord  produced  by  the  poisoned  blood,  rather  than 
of  a  disease  of  its  membranes  or  its  structure,  the  rigidity  runs 

*  Ogle,  Clinical  Society"s  Transactions.  1872. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  173  - 

so  uncertain  a  course,  appears  so  quickly,  disappears  so  suddenly, 
perhaps  not  to  reappear,  or  only  to  reappear  after  a  considerable 
interval,  that  there  is  little  likelihood  of  confounding  the  muscular 
disorder  with  tetanus.  In  cerebro-spinal  fever  the  resemblance  is 
much  closer ;  but  the  whole  history  of  the  disorder,  the  state  of  the 
mind,  and  the  progress  of  the  case,  are  such  as  to  prevent  error. 

Yet  another  form  of  symptomatic  rigidity  requires  to  be  dis- 
tinguished from  tetanus, — a  local  rigidity,  owing  to  the  irritation, 
of  the  nerve  supplying  the  stiffened  muscles ;  as,  for  instance,  a 
spasm  from  irritation  of  the  peripheral  or  the  central  tract  of  the 
motor  portion  of  the  fifth,  the  so-called  "masticatory  spasm"  of  the 
face.  This  curious  ailment  may  be  of  reflex  origin,  the  exciting 
cause  being  a  decayed  tooth,  a  wound,  or  exposure  to  cold ;  or  it 
may  exist  in  connection  with  apoplexy,  or  with  an  inflammation 
of  the  brain.  Its  main  marks  of  distinction  from  the  trismus  of 
tetanus  are,  that  it  is  purely  local,  is  often  of  long  continuance, 
is  not  painful,  has  no  paroxysms  of  aggravation,  is  not  combined 
with  impaired  deglutition,  and  is  not  dangerous.* 

Intermittent  tetanus,  or  idiopathic  muscular  spasm  of  the  ex- 
tremities, as  it  used  to  be  called,  is  characterized  by  tonic  con- 
tractions, more  especially  of  the  legs  and  arms,  occurring  at 
intervals;  the  toes  are  apt  to  be  flexed  toward  the  soles.  The 
disease  occurs  more  particularly  in  children,  and  in  women  after 
their  confinement.  The  jaws  and  the  respiratory  muscles  are, 
unlike  what  we  find  in  true  tetanus,  not  affected.f 

The  symptoms  of  strychnia  poisoning  are  almost  identical  with 
those  of  tetanus;  yet  there  are  some  characteristic  differences. 
The  spasms  from  strychnia  do  not  supervene  upon  exposure  to 
cold,  or  upon  a  wound ;  but  follow  within  about  two  hours  or  less 
the  taking  of  some  solid  or  liquid.  They  come  on  suddenly,  and 
with  violence ;  and  the  tetanoid  convulsions  affect  simultaneously 
nearly  all  the  voluntary  muscles  of  the  body,  but  with  greatest 
intensity  those  of  the  trunk  and  spine,  producing  very  early — 
within  a  few  minutes,  commonly — a  marked  opisthotonos,  which 
in  tetanus  does  not  appear,  if  it  appear  at  all,  for  many  hours  or 

*  Bright,  in  the  second  volume  of  his  Medical  Eeports,  gives  the  particulars 
of  a  case  which  illustrates  many  of  the  difficulties  of  diagnosis  to  which  the 
affection  may  give  rise. 

f  "Wilks,  Guy's  Hospital  Pxeports,  3d  Series,  vol.  svii. 


174  MEDICAL    DIAGNOSIS. 

for  days  after  the  seizure.  On  the  other  hand,  the  stiffness  of  the 
jaws,  which  is  among  the  very  earliest  signs  of  tetanus,  is  not  at 
first  perceived  in  strychnia  poisoning,  and,  if  it  occur,  occurs  only 
imperfectly.  Further,  we  do  not  see  the  frightful  tetanic  face, 
with  its  knit  brow  and  horrid  grin  ;  we  do  not  observe  intermis- 
sions in  the  convulsions,  or  difficulty  in  swallowing;  and  in  from 
ten  minutes  to  two  hours  after  the  commencement  of  the  attack 
the  patient  dies  or  recovers.* 

Finally,  let  us  contrast  tetanus  with  hydrophobia.  Both  show- 
ing the  reflex  functions  of  the  spinal  cord  to  be  in  an  exalted  con- 
dition ;  both  being  spasmodic  affections  lasting  ordinarily  but  a 
few  days ;  both  taking  place,  the  popular  opinion  to  the  contrary 
notwithstanding,  at  all  periods  of  the  year;  both  presenting  violent 
paroxysms  of  convulsions,  which  are  often  excited  by  the  slightest 
touch  or  jar  to  the  body ;  both  frequently  occasioning  torturing 
pain  near  the  pit  of  the  stomach ;  both  ensuing  commonly  upon 
an  injury;  both  usually  augmenting  in  intensity  from  hour  to 
hour,  and  scarcely  within  the  reach  of  therapeutic  measures, — 
these  ghastly  maladies  are  yet  dissimilar.  In  the  one,  deglutition 
may  be  difficult ;  in  the  other  it  is  next  to  impossible,  all  attempts 
at  swallowing,  especially  of  fluids,  exciting  the  most  distressing 
spasmodic  dysphagia.  In  the  one,  the  breathing  may  or  may  not 
be  interfered  with ;  in  the  other,  the  spasms  of  respiration  are 
almost  as  marked  a  feature  as  the  spasms  of  deglutition.  Then 
the  irritability  of  temper;  the  fierce  manner  of  the  patient;  his 
rabid,  perhaps  maniacal  paroxysms;  the  constant  thirst;  the  ac- 
cumulation of  stringy  mucus  about  the  angles  of  the  mouth  ;  the 
vomiting;  the  acute  sensibility  of  the  surface;  the  trembling  of 
the  muscles ;  the  clonic  instead  of  tonic  spasms ;  the  strangling 
sensation  in  the  throat, — are  phenomena  too  strikingly  peculiar  to 
render  an  error  in  diagnosis  likely.f  Some  of  the  points  here 
referred  to  serve  also  to  distinguish  hydrophobia  from  acute 
mania,  and  from  hysteria.  For  as  in  tetanus,  so  here  we  find 
this  erratic  complaint  simulating  the  terrible  disease. 

*  These  statements  are  based  on  the  researches  of  Taylor  (Guy's  Hospital 
Reports,  3d  Series,  vol.  ii.),  of  Todd,  and  of  Christison. 

|  For  instance,  a  case  referred  to  in  Guy's  Hospital  Reports,  vol.  xii.,  3d 
Series,  and  remarks  in  Gamgee's  article  on  Hydrophobia,  in  Reynolds's 
System  of  Medicine. 


DISEASES    OF     THE    BRAIN    AND    SPINAL    COED.  175 

Diseases  characterized  by  Gradual  Impairment  of  the  Mental 
Faculties  with  Paralysis, 

Chronic  Softening. — There  are  no  pathognomonic  symptoms 
the  presence  of  which  would  enable  us  to  declare  without  hesita- 
tion that  we  are  dealing  with  softening  of  the  brain,  or  the  absence 
of  which  would  justify  us  in  concluding  that  it  does  not  exist. 
Yet  a  large  number  of  cases  exhibit  uniform  manifestations  which 
permit  us  ordinarily  to  recognize  the  malady  with  some  degree 
of  certainty. 

There  are  two  main  forms  of  softening, — the  red  and  the  white. 
The  former  is  inflammatory, — a  circumscribed  encephalitis, — and 
runs  an  acute  course,  with  symptoms,  as  we  have  already  discussed, 
often  closely  simulating  those  of  apoplexy,  but  sometimes  with 
signs  like  those  of  the  chronic  malady,  and  differing  in  nothing 
but  in  their  intensity  and  short  duration.  The  second  kind  is 
chiefly  dependent  upon  a  change  in  the  nutrition  of  the  brain, 
and  is  most  often  linked  to  a  diseased  condition  of  the  cerebral 
arteries  and  plugging  of  the  vessels;  it  may,  however,  be  caused, 
or  at  all  events  accompanied,  by  an  inflammatory  exudation  in- 
filtrated among  the  nervous  pulp.  These,  briefly,  are  its  early 
symptoms :  gradual  impairment  of  intelligence ;  weakening  of 
memory;  headache;  vertigo;  muscular  debility;  cutaneous  hyper- 
esthesia or  anaesthesia;  formication  and  numbness;  and  slight 
and  partial  palsies,  particularly  of  the  muscles  of  one  side  of  the 
mouth,  or  of  one  eyelid.  Then  there  is  not  unfrequently  defective 
articulation,  with  great  irritability  of  temper,  nausea  and  vomiting, 
extreme  sensitiveness  to  sounds,  and  painful  feelings  in  various 
parts  of  the  body.  As  the  local  mischief  advances,  the  paralysis 
becomes  more  universal,  assuming  generally  the  hemiplegic  form; 
and  spasms,  either  tonic  or  clonic,  or  epileptic  convulsions  occur. 

The  mental  decay  proceeds  steadily,  and  sometimes  shows  itself 
in  a  constant  repetition  of  the  same  action  or  the  same  phrase.  In 
an  old  lady  whom  I  attended,  this  was  the  most  marked  symptom: 
she  was  constantly  complaining  of  her  teeth  needing  attention, 
was  perfectly  satisfied  when  assured  by  the  dentist  that  they  did 
not,  but  soon  reiterated  her  complaint.  Beyond  this,  and  a  most 
painful  sensitiveness  to  sound  and  to  light,  intense  headache, 
nausea,  and  a  progressive  deterioration  of  memory  and  of  the 


176  MEDICAL    DIAGNOSIS. 

faculty  of  thought,  she  presented  no  signs  of  cerebral  softening. 
She  died  without  the  occurrence  of  paralysis. 

Softening  of  the  brain  may  be  caused  by  a  diseased  state  of 
the  cerebral  vessels,  or  by  their  obstruction  ;  by  long-continued 
grief;  by  persistent  mental  labor;  by  constitutional  syphilis;  by 
frequently  repeated  epileptic  paroxysms ;  and  by  an  inflammatory 
disease  spreading  from  the  meninges  to  the  brain,  or  taking  place 
around  new  formations  and  old  lesions.  It  may  also  be  depend- 
ent upon  apoplexy.  At  all  events,  we  frequently  meet  with  it 
in  connection  with  hemorrhage,  and  associated  sometimes  in  a 
manner  to  make  it  a  very  perplexing  matter  to  ascertain  if  the 
softening  have  followed  the  extravasation  of  blood,  or  if  the  ex- 
travasation have  taken  place  into  an  already  diseased  brain.  AVe 
may  conclude  the  latter  to  have  occurred,  if  signs  of  deranged 
intellection  or  sensation  have  preceded  the  attack ;  if,  soon  after 
reaction  from  the  shock,  the  patient,  instead  of  mending  in  mind, 
exhibit  unmistakable  evidences  of  progressing  mental  decay ;  and 
if  convulsive  movements  or  rigidity  of  the  limbs  appear. 

It  is,  indeed,  by  this  combination  of  signs  alone  that  we  are 
enabled,  whatever  may  be  the  relations  of  the  softening;  to  the 
hemorrhage,  to  decide  whether,  after  an  apoplectic  seizure,  soft- 
ening be  present  at  all ;  a  decision  practically  of  much  more  con- 
sequence than  the  determination  whether  the  cerebral  disorgani- 
zation did  or  did  not  exist  prior  to  the  bleeding.  And  let  us, 
in  passing,  remark  that  a  small  clot  breaking  down  the  softened 
cerebral  mass,  yet  not  extending  beyond  the  limits  of  the  diseased 
texture,  occasions  no  special  signs, — occasions  only  the  signs  of 
a  sudden  giving  way  of  nerve-pulp:  paralysis  without  uncon- 
sciousness. 

We  shall  next  study  how  various  other  cerebral  maladies,  such 
as  congestion,  anaemia,  abscess,  and  hardening,  may  be  distin- 
guished from  softening. 

Congestion  is  discriminated  by  its  being  very  rarely  a  persistent 
state.  An  acute  attack  produces  the  symptoms  of  apoplexy ;  a 
more  lasting  congestion  is  recognized  by  tracing  the  cause  which 
has  led  to  the  fulness  of  the  vessels, — such  as  an  interference  with 
the  circulation,  the  result  of  a  disease  of  the  circulatory  system 
itself,  or  of  the  abdominal  viscera, — and  by  noting  that,  although 
the  patient  suffers  from  dull  headache,  from  jerking  of  the  muscles, 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  177 

from  pulsation  of  the  carotids,  from  vertigo,  these  signs  are  far 
from  being  constant,  and  come  and  go  for  a  long  time  without 
any  material  disturbance  of  the  functions  of  the  brain  being  per- 
ceptible, in  reference  either  to  thought  or  to  voluntary  motion. 
The  finding  of  optic  neuritis,  or  choked  disk,  would  settle  any 
doubt  against  congestion. 

Cerebral  anaemia  is  a  state  in  which  the  supply  of  blood  in  the 
brain  is  diminished,  and  usually  also  altered.  Occurring  suddenly, 
it  produces  unconsciousness,  or  dizziness  or  stupor,  or,  if  very 
general,  and  especially  if  associated  with  venous  congestion, 
it  may  cause  convulsions.  When  more  gradually  induced,  it 
manifests  itself  by  drowsiness,  distressing  headache,  often  more 
particularly  referred  to  the  vertex ;  by  the  pale  face  and  uninjected 
eye  with  large  ixipil ;  by  derangement  of  the  special  senses ;  by 
the  vertigo  and  the  other  symptoms  of  cerebral  disorder  being 
relieved  in  the  recumbent  position ;  and  by  the  feeble  pulse  and 
cool  forehead.  Then  in  tracing  its  history  we  are  apt  to  find  that 
it  occurs  in  those  who  have  been  exhausted  by  debilitating  dis- 
eases, or  by  repeated  hemorrhages,  or  by  albuminuria.  The  chief 
distinction  from  softening  lies  in  the  history  of  the  case;  the 
aspect  of  the  patient,  too,  and  the  absence  of  palsies,  or  their  pass- 
ing nature,  must  be  taken  into  account.  But  we  must  not  forget 
that  if  the  morbid  condition  be  long  continued,  the  ill-nourished 
brain  will  soften. 

Abscess  of  the  brain  differs  mainly  in  this  from  chronic  soften- 
ing :  the  disease  is  of  short  duration.  Some  cases  may  run  a  very 
rapid  course,  others  may  continue  for  months ;  yet  few,  as  Lebert* 
has  informed  us,  last  longer  than  eight  weeks.  Further,  we  find 
in  abscess,  unlike  what  hapj^ens  in  softening,  convulsions  in  the 
earlier  period,  and  paralysis  late  in  the  malady;  and  not  unfre- 
quently  we  discover,  in  analyzing  the  history,  that  chills  have 
occurred,  or  we  can  detect  the  clue  to  the  cerebral  abscess  in  a 
disease  of  the  internal  ear,  or  in  an  injury  to  the  head,  or  in  the 
presence  of  a  suppurative  process  in  some  distant  part  of  the 
body.  In  the  early  stages  abscess  is  often  latent,  and  at  any 
stage  hemiplegia  and  contractions  are  far  less  common  in  it  than 


*  Arehiv  fiir  Path.  Anat.   Bd.  x.     See,  also,  Gull's  paper  in  Guy's  Hospital 
Eeports,  3d  Series,  vol.  iii. 

12 


178  MEDICAL    DIAGNOSIS. 

in  softening.  Cases  of  red  softening  cannot  be  distinguished  from 
cerebral  abscess,  especially  from  those  cases  which  run  a  rapid 
course.     In  truth,  the  two  morbid  states  are  often  combined. 

Hardening  of  the  cerebral  substance  is  in  adults  rarely  seen 
except  as  the  result  of  lead  poisoning,  or  as  forming  part  of 
disseminated  cerebro-spinal  sclerosis.  But  when  existing  alone, 
the  pain  in  the  course  or  at  the  extremities  of  peripheral  nerves, 
the  double-sided  palsy  spreading  from  the  extremities  up,  the 
frequency  of  convulsions  and  of  muscular  contractions,  and  the 
remissions  in  the  symptoms,  serve  to  distinguish,  so  far  as  it  can 
be  distinguished,  cerebral  induration  from  cerebral  softening. 
Sometimes  hardening  is  found  in  connection  with  atrophy  of  the 
brain  ;  but  this  lesion  is  beyond  the  reach  of  diagnosis. 

There  is  yet,  leaving  tumors  out  of  the  question,  another  affec- 
tion of  the  brain  which  maybe  confounded  with  softening:  an 
exhaustion  of  brain-power,  encountered  among  professional  men 
or  those  engaged  in  laborious  literary  undertakings.  This  some- 
times comes  on  suddenly,  with  signs  like  tho^e  of  a  collapse ;  more 
generally  it  is  slower  in  development.  Its  manifestations  are  a 
slight  deterioration  of  memory,  and  an  inability  to  read  or  write, 
save  for  a  very  short  period,  although  the  power  of  thought  and 
of  judgment  is  in  no  way  perverted.  Nor  is  the  power  of  atten- 
tion more  than  enfeebled :  the  sick  man  is  fully  capable  of  giving 
heed  to  any  subject,  but  he  soon  tires  of  it,  and  is  obliged  from 
very  fatigue  to  desist.  He  passes  sleepless  nights,  is  subject  to 
ringing  in  the  ears,  cannot  bear  much  exercise,  is  troubled  with 
irregular  action  of  the  heart,  with  a  frequent  desire  to  urinate, 
and  with  neuralgic  pains  in  the  face  or  a  feeling  of  soreness  in  the 
head ;  but  he  does  not  lose  flesh,  and  his  digestion  is  uninjured. 

Many  remain  in  this  condition  for  months,  and  then  slowly 
regain  their  health.  What  the  precise  disturbance  of  the  brain 
consists  in,  is  uncertain :  it  is  possible  that  the  nutrition  of  the 
organ  has  been  interfered  with  from  overuse  and  worry,  and  that 
the  further  continuance  of  mental  toil  and  anxiety  would  have 
led  to  softening.  The  phenomena  differ  from  those  of  this  serious 
cerebral  disease  by  the  absence  of,  or  at  least  by  the  far  less  per- 
manent and  marked,  headache,  by  the  comparatively  unimpaired 
intelligence,  and  by  the  no n- occurrence  of  spasms,  or  of  paralysis 
of  motion  or  of  sensation. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  179 

Let  us  now  consider  the  diagnosis  of  the  chief  varieties  of  soft- 
ening. In  how  far  is  it  possible  to  distinguish  the  inflammatory 
from  the  non-inflammatory  form  ?  The  more  acute  the  symptoms, 
the  greater  is  the  likelihood  of  their  being  due  to  an  inflammatory 
lesion ;  and  in  young  subjects  this  probability  becomes  almost  a 
certainty.  A  latency  of  the  affection,  its  slow  and  gradual  mani- 
festation, its  existence  in  persons  advanced  in  life,  and  in  whom 
we  have  reason  to  suspect  degeneration  of  the  coats  of  the  arteries, 
or,  on  the  other  hand,  a  history  pointing  to  closure  of  the  vessels 
by  a  plug,  or  to  an  embolus  washed  into  them  from  a  diseased 
heart,  are  facts  which  justify  the  conclusion  that  the  softening  is 
owing  to  a  depraved  nutrition  of  the  cerebral  substance,  and  not 
to  its  inflammation. 

Softening  may  occur  in  the  brain  of  infants,  but,  as  Parrot* 
shows,  cannot  be  diagnosticated. 

Tumor. — Tumors  of  the  brain  give  rise  to  a  great  diversity 
of  signs,  according  to  their  locality,  their  size,  and  their  nature. 
Let  us  examine  the  peculiar  symptoms,  or  group  of  symptoms, 
by  which  we  may  infer  their  occurrence,  and  then  see  in  how  far 
an  attempt  to  distinguish  their  seat  and  precise  nature  is  likely 
to  succeed. 

The  presence  of  a  tumor  in  the  brain  is  rendered  probable  if, 
in  addition  to  vertigo,  to  vomiting  or  to  a  disposition  to  vomit,  or 
to  headache,  violent  but  paroxysmal  and  neuralgic  in  its  character, 
we  find  impairment  or  loss  of  vision,  or  indeed  anaesthesia  of  any 
special  sense,  and  epileptiform  convulsions  not  followed  by  any 
greater  deterioration  of  health  than  previously  existed ;  if  with 
these  signs  of  cerebral  irritation  the  intellect  is  not  at  first  markedly 
disordered,  nor  the  articulation  affected ;  and  if  paralyses  do  not 
show  themselves  until  a  very  long  time  after  the  headache,  and  are 
even  then  limited  to  the  muscles  of  the  eyeball  or  of  the  face,  or 
to  the  muscles  of  the  extremities  of  one  side  of  the  body.  As  a 
further  sign  of  cerebral  tumor,  we  may  class  the  discovery  of  optic 
neuritis,  or  choked  disk.  ■  Yet  before  the  evidence  is  considered 
conclusive,  we  must  exclude  other  chronic  cerebral  maladies,  espe- 
cially softening,  abscesses,  and  chronic  meningitis. 

We  separate  softening  by  noticing  that  the  headache  caused  by 

*  Archives  de  Physiologie,  March,.  1873- 


180  MEDICAL    DIAGNOSIS. 

a  tumor  is  much  more  violent  and  paroxysmal,  not  dull  or  of 
steady  intensity ;  that  the  intelligence  remains  for  a  long  time 
intact,  save,  perhaps,  in  a  weakening  of  the  memory  :  that  motor 
and  sensory  disturbances  are  less  frequent  and  prominent,  but 
convulsions  far  more  so.  Remissions,  or  intervals  of  apparent 
improvement,  occur  in  both  morbid  states;  but  they  are  more 
perfect  and  of  longer  duration  in  tumor  than  in  softening. 

The  differential  diagnosis  between  tumor  and  abscess  is  more 
difficult.  "We  may  conclude  the  latter  to  furnish  the  explanation 
of  the  signs  of  cerebral  pressure  or  disorganization,  if  the  cephal- 
algia be  sudden  in  its  development,  and  uniform  and  general, 
instead  of  neuralgic  and  limited.  Then,  convulsions,  drowsiness, 
paralysis,  and  coma  succeed  one  another  much  more  rapidly  and 
much  more  constantly  in  abscess  than  in  tumor, — a  malady  run- 
ning a  very  chronic  course,  and  in  which  the  patient  does  not 
remain  drowsy  or  palsied  after  the  epileptiform  seizures.*  If, 
moreover,  we  obtain  the  history  of  injury  to  the  skull,  or  find  a 
discharge  from  the  ear,  or  pain  upon  pressure  over  the  mastoid 
process,  or  a  chronic  disease  about  the  head,  or  albuminous  urine, 
or  protracted  suppuration  in  any  part  of  the  body,  Ave  may  safely 
infer  that  an  abscess,  not  a  tumor,  is  the  cause  of  the  evident 
cerebral  mischief. 

Chronic  meningitis,  an  affection  sometimes  complicating  tumor, 
is  discriminated  bv  laving;  stress  on  its  etiological  relations, — such 
as  blows  upon  the  head,  diseases  of  the  bones,  syphilis,  or  rheuma- 
tism ;  and  by  observing  its  frequent  though  irregular  accessions  of 
fever,  the  great  irritability  of  temper,  the  dulness  of  intellect,  the 


*  I  have  mentioned  epileptic  seizures  in  these  affections  because  I  believe 
they  belong  to  them.  But  Brown-Sequard  has  stated  (quoted  in  Am.  Journ. 
of  Med.  Sciences.  April,  1809,  p.  531)  that  disease  of  the  cerebral  substance  is 
incapable  of  producing  epileptic  symptoms,  and  that  when  these  occur  they  are 
to  be  attributed  to  concomitant  lesions  of  the  meninges.  "Whatever  the  cause, 
the  epileptic  fits  may  be  absent.  Thus,  they  occurred  in  only  thirty-eight 
cases  of  abscess  of  the  brain  out  of  seventy-three  collected  by  Gull  and  Sutton 
(see  article  "Abscess  of  Brain,'"  in  Reynolds's  System  of  Medicine).  Again, 
both  affections  may  be  latent.  Particularly  is  this  the  case  with  cerebral 
abscess  ;  and  the  sudden  rupture  of  the  abscess  may  give  rise  to  symptoms 
undistinguishable  from  those  of  hemorrhage,  undistinguishable  unless  we  can 
infer  an  abscess  from  a  disease  of  the  bones  of  the  skull,  or  from  some  points 
in  the  historv  of  the  case. 


DISEASES    OF    THE    BEAIN    AND    SPINAL    COED.  181 

loss  of  memory,  and  the  nocturnal  delirium.  The  pain,  too,  is,  as 
a  rule,  somewhat  duller  and  more  diffused  than  in  tumor,  though 
more  fixed  and  constant,  and  there  is  more  vertigo ;  but  the  con- 
vulsions, on  the  other  hand,  are  less  distinctly  epileptiform  in  type; 
yet  convulsive  movements  of  some  muscles  are  very  common,  and 
may  even  be  followed  by  incomplete  paralysis.  Meningitis  may 
be  excluded,  Hughlings  Jackson  tells  us,  if  double  optic  neuritis 
or  any  very  marked  alteration  of  the  disks  be  found  early  in  the 
case. 

Thrombosis  of  the  sinuses  of  the  brain  may  occasion  partial  pal- 
sies, and  the  symptoms  of  cerebral  pressure,  like  those  of  tumors, 
and  cannot  be  distinguished  except  in  those  instances  in  which 
we  can  find  distention  of  the  collateral  circulation  and  injection 
and  oedema  of  the  forehead  and  eyelids.*  Convulsions,  further, 
are  very  rarely  among  the  symptoms. 

The  precise  seat  of  the  tumor  it  is  impossible  to  determine. 
An  affection  of  the  special  senses  points  to  disease  near  to,  or  at, 
the  base  of  the  brain ;  and  the  probability  of  this  view  is  much 
strengthened  if  there  be  paralysis  of  the  face  on  the  side  opposite 
to  that  of  the  extremities,"}"  and  if  vigorous  inspiration,  during 
which  the  brain  falls  and  presses  the  morbid  mass  against  the 
walls  of  the  base  of  the  skull,  cause  or  increase  pain;  whereas,  so 
says  that  high  authority,  Romberg,  in  tumors  on  the  upper  sur- 
face, forced  expiration  produces  a  like  result.  In  tumors  of  the 
cerebellum  we  have  headache,  severe,  often  bilious  vomiting,  and 
staggering  gait,  also  spasms,  rigidity,  and  tetanic-like  seizures;  but 
there  may  be  no  marked  alteration  of  the  disks.  Then  as  regards 
the  exact  position  of  the  tumor  we  must  bear  in  mind  the  local- 
ization of  the  cerebral  functions,  which  recent  research  is  eluci- 
dating for  us.  The  difficulty  of  applying  this  extending  knowl- 
edge to  the  diagnosis  of  tumors  at  the  bedside  is  that  they  may 
give  rise  to  circumscribed  inflammation  around  them,  or  to  irrita- 
tion in  even  somewhat  more  remote  parts,  and  that  the  special 
manifestations  of  the  disorder  of  the  part  affected  by  the  tumor 
are  thus  blurred  or  obscured. 

*  Heubner,  quoted  in  Schmidt's  JahrbGcher,  No.  1,  1869. 

f  But  as  regards  the  palsy  of  the  face  being  on  the  side  opposite  to  that  of 
the  body,  this  depends  very  much  upon  the  exact  position  and  extent  of  the 
lesion,  as  has  been  explained  while  discussing  hemiplegia. 


182  MEDICAL    DIAGNOSIS. 

And  what  shall  we  say  of  the  nature  of  a  tumor  of  the  brain '? 
Can  we  form  an  opinion  regarding  it  from  any  of  the  signs  refer- 
able to  the  cerebral  disorganization?  We  cannot:  the  character 
of  the  pain  has  been  thought  to  be  of  great  significance ;  but  the 
testimony  to  prove  that  it  is  so,  is  in  the  highest  degree  unsatis- 
factory. We  may  sometimes,  however,  from  the  history  of  the 
case,  or  from  the  existence  of  some  of  the  manifestations  of  special 
cachexia,  draw  a  correct  inference.  For  instance,  if  we  find  dis- 
ease of  the  lungs,  or  any  evidences  of  scrofula,  and  the  patient  is 
young,  we  shall  probably  be  right  in  conjecturing  the  tumor  of 
the  brain  to  be  a  mass  of  tubercle;  but  if  the  sufferer  is  advanced 
in  years,  and  exhibits  tumors  in  various  parts  of  the  body,  and 
further  signs  of  a  cancerous  diathesis,  we  may  with  reasonable 
certainty  presume  the  tumor  within  the  skull  to  be  cancerous. 
Other  kinds  of  tumors  and  deposits  can  scarcely  be  said  to  be 
within  the  reach  of  diagnosis.  Cysts  seated  in  the  superficial 
portions  of  the  brain  either  occasion  no  symptoms,  or  give  rise 
to  headache,  to  attacks  of  vertigo,  to  vomiting,  and  to  epileptic 
seizures,  but  very  rarely  to  palsies.  The  symptoms  mentioned 
are  far  more  apt  to  be  present  when  the  cysts  occupy  the  lateral 
ventricles;  then  epileptic  convulsions  especially  are  very  rarely 
absent. 

The  symptoms  of  an  aneurism  within  the  cranium  are  usually 
those  of  an  ordinary  tumor,  and  the  affection  is  not  distinguishable 
except  when  we  find  decided  indications  of  disease  of  the  vessels 
in  other  parts  of  the  system.*  Neither  the  presence  nor  the  ab- 
sence of  a  subjective  feeling  of  pulsation  and  of  a  murmur  has 
a  positive  significance;  for,  notwithstanding  the  cases  of  Jona- 
than Hutchinsonf  and  Humble,!  in  which  the  diagnosis  was  made 
during  life,  the  detection  of  a  murmur,  as  I  know  from  observa- 
tion, is  not  a  certain  sign.  In  aneurism  of  the  vertebral  arteries 
epilepsy  is  a  constant  symptom. § 

General  Paralysis. — This  fatal  and  obscure  cerebral  malady 
resembles  softening  of  the  brain, — nay,  softening  is  frequently 
found  after  death ;  but  there  may  be  atrophy  with  hardening,  or 

*  James  H.  Hutchinson,  Pennsylvania  Hospital  .Reports,  vol.  ii. 

f  British  Medical  Journal,  April,  1875. 

X  London  Lancet,  Oct.  187">. 

§  Bartholow,  American  Journal  of  the  Medical  Sciences,  Oct.  1872. 


DISEASES    OF    THE    BRAIN    AND    SPINAL  CORD.  183 

other  morbid  changes,  and  the  affection  is  now  recognized  by 
most  pathologists  as  a  diffuse  interstitial  encephalitis.  Clinically, 
the  disorder  is  marked  by  impairment  of  the  powers  of  locomo- 
tion ;  by  an  inability  to  articulate  distinctly, — a  symptom  which 
precedes  the  deranged  locomotion;  by  the  peculiar  meaningless 
countenance ;  and  by  complete  perversion  of  the  mental  faculties, 
amounting  ordinarily,  in  fact,  to  insanity. 

The  palsy  is  peculiar:  indeed,  Skae*  says  that,  in  the  usual 
sense  of  the  term,  there  is  no  palsy  in  the  limbs  at  all ;  there  is 
rather  a  want  of  control  over  their  co-ordinate  action,  displaying 
itself  in  a  swaying  from  side  to  side  when  the  patient  attempts  to 
walk.  The  impairment  of  the  muscular  movement  gradually 
extends :  there  is  a  tremulousness  in  the  muscles  of  expression ; 
the  speech  becomes  more  inarticulate,  until  scarcely  a  word  can  be 
distinguished ;  and  the  patient  cannot  rise  without  being  assisted. 
The  cutaneous  sensibility  is  greatly  diminished  or  is  lost.  The 
mental  derangement  is  marked  by  an  exaggerated  sense  of  personal 
power  or  importance,  and  fancies  of  great  wealth.  Apoplectiform 
seizures,  accompanied,  like  those  in  multiple  sclerosis,  by  consider- 
able elevation  of  temperature,  are  not  uncommon.  Death  is  often 
preceded  by  convulsive  attacks  and  by  coma,  or  by  painful  contrac- 
tions of  the  muscles  of  the  trunk  or  extremities,  or  by  obstinate 
diarrhoea,  or  by  pulmonary  troubles. f 

The  strange  malady  differs  from  other  forms  of  extensive  gen- 
eral paralysis  in  being  far  less  of  a  real  palsy.  It  is  certainly  far 
less  complete  than  the  extensive  paralyses  which  follow  lesions  of 
the  upper  portion  of  the  spinal  cord,  or  which  are  consequent  upon 
the  poison  of  lead,  or  of  malaria,  or  of  diphtheria.  Its  association 
with  marked  disturbance  of  the  intellect  furnishes,  moreover,  a 
differential  test  of  great  value,  and  not  merely  with  reference  to 
the  general  palsies  just  mentioned,,  but  also  as  regards  the  trem- 
bling movements  of  old  age,  of  progressive  muscular  atrophy, 
and  of  chronic  alcoholism. 

The  defect  in  the  articulation  and  the  attending  tremor  of  the 
lips  may  cause  the  disease  to  be  mistaken  for  cerebrospinal  scle- 
rosis and  paralysis  agitans.     But  in  the  former  of  these  affections, 


*  Edinburgh  Medical  and  Surgical  Journal,  April,  1860. 

|  Calmeil,  Traite  des  Maladies  inflammatoires  du  Cerveau,  Paris,  1858. 


184  MEDICAL    DIAGNOSIS. 

while  the  embarrassed,  scanning  speech  coexists  with  great  help- 
lessness of  manner,  with  oscillation  of  the  eyeballs,  with  tremor 
manifesting  itself  only  on  motion,  with  paresis  of  the  lower  limbs, 
and  finally  with  permanent  contractions,  we  do  not  notice  a  decided 
alienation  of  mind,  nothing  more  than  general  enfeeblement  and 
blunted  emotional  faculties.  Then  it  is  a  disease  very  rarely  met 
with  in  persons  over  forty  years  of  age,  being  most  common  be- 
tween twenty-five  and  thirty.  In  paralysis  agitans  the  voice  is 
not  really  tremulous;  there  is  rather  a  monotonous  tone  and  slow 
utterance,  and  we  find  fixed,  expressionless  features,  which,  with 
the  restlessness,  the  sensation  of  excessive  heat,  the  peculiar  gait 
and  attitude,  the  unaltered  cutaneous  sensibility,  the  tremor  ever 
present  except  during  sleep,  yet  the  head  taking  no  share  in  the 
trembling,  the  manner  in  which  the  patient  when  attempting  to 
walk  is  propelled  forward,  and  the  very  long  duration  of  the 
symptoms,  characterize  the  disease.  The  intellect  becomes  ob- 
scured toward  the  end  of  the  malady,  but  not  before. 

Diseases  characterized  by  Enlargement  of  the  Head. 

Chronic  Hydrocephalus. — The  signs  of  dropsy  of  the  brain 
are,  progressive  enlargement  of  the  head,  and  a  perversion  or  a 
gradual  loss  of  one  or  several  of  the  special  senses,  of  the  mental 
faculties,  and  of  the  power  of  voluntary  motion.  The  child  can- 
not bear  the  weight  of  the  head ;  the  gait  is  tottering  and  uncer- 
tain. The  intellect,  slowly  but  certainly,  becomes  deranged.  As 
the  malady  advances,  strabismus,  partial  palsies,  epileptic  convul- 
sions, vomiting,  cutaneous  anaesthesia,  and  loss  of  sight,  of  smell, 
and  of  taste,  are  observable;  the  bowels  become  very  constipated; 
and  a  copious  secretion  of  tears  and  of  saliva  is  not  infrequent. 

Before  death  takes  place,  which  sometimes  does  not  happen  for 
years,  the  child  ordinarily  becomes  idiotic.  A  few  cases  recover ; 
fewer  reach  adult  age  with  their  brain  compressed  by  the  accumu- 
lated fluid ;  in  still  fewer  the  disease  does  not  develop  itself  until 
after  childhood.  If  the  patient  survive  until  adult  a^e,  the  size 
of  the  skull  is  generally  immense.  I  saw,  a  few  years  since,  a 
young  man,  twenty-two  years  of  age,  whose  head  measured  fully 
two  feet  and  a  half  in  circumference.  He  could  walk  unaided, 
but  often  fell.     He  was  half  idiotic,  and  subject  to  epileptic  fits ; 


DISEASES    OP    THE    BRAIN    AND    SPINAL    CORD.  185 

yet  he  had  sufficient  intelligence  to  understand  what  was  said  to 
him,  and  in  his  childish  way  to  do  as  he  was  told. 

The  skull  is  sometimes  very  large  without  dropsy  of  the  brain 
existing.  The  head  may  be  overgrown,  and  its  bones  thickened 
and  spongy,  as  in  rachitis;  or  it  may  be  large  when  there  is  no 
disease.  These  states  differ  from  chronic  hydrocephalus  by  the 
absence  of  cerebral  symptoms;  and  in  doubtful  cases  we  may  call 
in  the  ophthalmoscope  as  a  means  of  diagnosis.  The  vessels  of  the 
eye,  even  in  the  early  stages  of  chronic  hydrocephalus,  enlarge, 
and,  in  proportion  as  the  serum  compresses  the  brain,  we  find  an 
increase  of  vascularity  in  the  retina,  with  dilatation  of  its  veins, 
and  with  an  increase  of  the  number  of  its  vessels;  complete  or 
partial  serous  infiltration  of  the  retina ;  and  an  atrophy,  more  or 
less  perceptible,  of  the  optic  nerve.  These  lesions  vary  with  the 
age  of  the  disease  and  the  amount  of  serous  effusion;  but  none  of 
them  exist  in  rickets.*  Then  in  rickets  the  tendency  is  to  spasm 
of  the  glottis,  to  diarrhoea, — not,  as  in  hydrocephalus,  to  consti- 
pation. The  size  of  the  head  may  also  be  augmented  in  conse- 
quence of  meningeal  apoplexy,  or  of  hypertrophy  of  the  brain. 
The  former  may  be  suspected  if  the  distention  of  the  cranium 
follow,  at  no  very  long  interval,  an  attack  of  convulsions  and 
of  coma  in  a  teething  child. 

Hypertrophy  of  the  Brain. — A  complaint  in  which  the 
brain  develops  with  disproportionate  rapidity  to  the  growth  of  its 
bony  case,  which  thus  becomes  too  small  for  its  contents. 

The  symptoms  this  morbid  state  occasions,  irrespective  of  the 
enlargement  of  the  head,  are  headache,  vertigo,  drowsiness,  and 
epileptiform  convulsions.  The  gait  is  very  unsteady ;  the  mind 
gradually  gives  way.  After  the  paroxysms  of  headache  and  of 
convulsions  we  often  find  stupor,  which  may  deepen  into  fatal 
coma.     Sometimes  delirium,  or  even  mania,  is  noticed. 

Hypertrophy  of  the  brain  requires  to  be  carefully  distinguished 
from  the  enlargement  of  the  head  which  takes  place  when  both 
the  brain  and  the  skull  increase  rapidly ;  a  hypertrophy  too,  in 
a  certain  sense,  but  not  a  hypertrophy  fraught  with  danger  or 
occasioning  any  morbid  manifestations. 

Equally  important  is  it  to  discriminate  between  the  augmented 

*  Bouchut,  op.  cit. 


186  MEDICAL    DIAGNOSIS. 

brain  and  chronic  hydrocephalus.  Unfortunately,  the  marks  of 
distinction  are  not  very  clearly  traced.  Both  diseases  have  much 
the  same  symptoms;  both  are  generally  of  long  duration.  There 
is,  however,  in  many  cases,  this  dissimilitude:  in  hypertrophy  the 
convulsions  are  a  much  more  marked  phenomenon,  and  they  pre- 
cede, rather  than  accompany,  the  signs  of  failing  intellect  and  of 
cerebral  pressure.  The  changes  in  the  special  senses  are  not  so 
common,  or  so  prominent;  there  is  not,  when  the  fontanelles  are 
touched,  the  sensation  of  a  tense  membrane  filled  with  water,  but 
rather  of  a  solid  substance  ;  and  the  body  does  not  waste  as  in 
dropsy  of  the  brain. 

Manthner*  lays  great  stress  on  the  different  shapes  of  the  head. 
In  chronic  hydrocephalus,  he  states,  the  forehead  is  the  first  to 
enlarge,  and  the  posterior  part  of  the  skull  does  not  expand  until 
long  afterward  ;  in  hypertrophy  the  reverse  takes  place.  But  this 
is  not  a  sign  free  from  doubt ;  indeed,  it  may  be  looked  upon  as 
of  very  questionable  value.  The  same  may  be  said  with  regard 
to  the  observation  of  West,  that  in  hypertrophy  there  is  no  prom- 
inence, but  an  actual  depression,  of  the  anterior  fontanelle,  and 
that  a  similar  depression  is  observable  at  all  the  sutures. 

Diseases  characterized  by  Paroxysmal  Pain. 

There  is  a  group  of  nervous  disorders  characterized  solely  by 
pain,  which  is  confined  ordinarily  to  one  nerve  and  is  seemingly 
seated  in  it.  These  nervous  pains  bear  the  generic  name  of  neu- 
ralgia. They  are  acute,  follow  the  course  of  a  nervous  branch, 
and  come  on  in  paroxysms  having  distinct  exacerbations,  succeeded 
by  distinct  intermissions.  In  some  cases  these  intermissions  are 
long,  in  others  short ;  in  some  they  are  complete,  in  others  the  pain 
is  lasting  and  becomes  from  time  to  time  exalted, — rather  remis- 
sions, therefore,  than  intermissions.  Save  in  the  rarest  instances, 
the  excruciating  sensations  are  not  complicated  with  heat  and 
swelling.  Nor  is  there  tenderness,  except  when  the  neuralgia  is 
of  long  continuance  ;  at  least  there  is  not  tenderness  along  the 
aching  nerve,  though  we  may  find  certain  sensitive  spots,  which, 
in  the  case  of  the  spinal  nerves,  are  readily  detected  by  pressing 

*  Krankheiten  des  Gehirns,  etc.,  Vienna,  1844. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  187 

on,  or  to  one  side  of,  the  spinous  process  of  the  vertebra  near 
which  the  affected  nerve  emerges,  and  by  examining  the  points  of 
terminal  expansion.  These  painful  spots  are  often  looked  upon  as 
proving  the  presence  of  what  is  vaguely  called  "  spinal  irritation." 

The  pain  of  neuralgia  is,  then,  of  a  purely  nervous  character, 
and  exists  independently  of  inflammation,  or  of  any  recognizable 
textural  change  of  the  nervous  centres  or  nervous  trunks.  This 
we  must  always  bear  in  mind  before  concluding  the  complaint  to 
be  neuralgia ;  seeking  carefully  for  the  signs  of  a  disturbance  of 
the  nervous  centres  or  of  the  larger  nervous  trunks  before  the 
morbid  excitation  of  sensibility  is  looked  upon  as  forming  the 
whole  disorder.  And  it  is  only  when,  after  a  minute  search, 
we  can  detect  no  definite  organic  cause  for  the  local  pain,  that  we 
may  set  down  our  patient  as  laboring  under  neuralgia. 

From  the  characteristics  of  the  pain  just  mentioned,  it  is  evi- 
dent that  it  is  not  likely  to  be  confounded  with  that  of  local 
inflammation.  But  there  is  a  kind  of  local  pain  for  which  neu- 
ralgia is  often  mistaken  :  the  pain  of  subacute  or  of  chronic  rheu- 
matism. Yet  this  is  in  reality  very  dissimilar.  The  rheumatic 
pain  is  attended  with  soreness,  is  aggravated  by  movement  or  by 
pressure,  is  more  diffuse  and  irregular,  much  more  constant,  much 
more  influenced  by  alternations  of  temperature,  but  not  acute  or 
paroxysmal,  and,  finally,  not  limited  anatomically  to  the  course 
of  one  nerve,  but  scattered  over  parts  supplied  by  several.  Ex- 
cept the  influence  of  the  weather,  the  pain  of  myalgia  presents 
much  the  same  points  of  difference,  in  addition  often  to  the  history 
of  a  muscular  strain. 

The  source  of  the  neuralgia  should  always  be  determined  as 
closely  as  possible,  on  account  both  of  the  prognosis  and  of  the 
treatment.  In  many  cases  it  will  be  found  to  be  connected  with 
ansemia;  in  others,  with  the  poison  of  rheumatism,  of  gout,  of 
syphilis,  or  of  uraemia.  It  is  often  reflex,  the  pain  being  far  away 
from  the  seat  of  the  disease,  and  due  to  irritation  reflected  through 
the  nervous  centres.  For  instance :  an  affection  of  the  digestive 
apparatus,  of  the  liver,  or  of  the  kidneys,  may  give  rise  to  neu- 
ralgia in  parts  quite  remote  from  them.  It  is  evident  that  if 
such  be  the  origin  of  the  disorder,  and  if  the  malady  which  lies 
at  its  root  and  excites  it  can  be  controlled,  the  neuralgia  will  si- 
multaneously disappear.     Yet  it  must  be  confessed  that  we  cannot 


188  MEDICAL    DIAGNOSIS. 

always  detect  the  cause,  whether  or  not  it  be  of  the  nature  just 
mentioned,  and  we  have  often  to  treat  the  neuralgia  by  employing 
those  agents  which  are  suitable  to  the  greatest  number  of  cases. 
And  it  must  be  added  that  such  treatment  receives  a  scientific  en- 
dorsement from  the  view  of  Anstie,  that  peripheral  irritants  have, 
after  all,  very  little  to  do  with  neuralgia,  but  that  it  depends  upon 
a  local  and  inherited  defect  in  a  particular  centre  or  in  several 
nerve-centres. 

Neuralgia  may  occur  in  any  portion  of  the  body.  It  may  shift 
rapidly  from  one  part  to  another,  as  in  that  peculiar  neuralgia  de- 
scribed by  Putegnat,*  excited  by  a  desire  to  pass  water  and  by  the 
act  of  micturition,  beginning  with  numbness  and  acute  burning 
or  lancinating  pain  along  the  urinary  passages,  then  affecting 
particularly  the  nerves  of  the  forearm,  especially  the  ulnar,  and 
disappearing  completely  after  micturition.  The  most  frequent 
seat  of  neuralgia  is  perhaps  about  the  head ;  and  we  shall  here 
notice  chiefly  a  few  of  its  most  common  kinds.  Most  of  the  other 
varieties  of  the  disorder,  and  especially  intercostal  neuralgia  and 
some  of  the  abdominal  forms,  will  be  elsewhere  alluded  to. 

Facial  Neuralgia. — The  facial  branches  of  the  fifth  pair  are 
often  the  site  of  agonizing  pain.  But  all  the  branches  of  the  nerve 
are  not  equally  liable:  the  lowermost  of  them  is  rarely  affected. 
When  the  supra-orbital  division  is  the  seat  of  the  ailment,  the 
pain  shoots  to  the  forehead,  the  eyebrow,  and  the  eyeball,  which  is 
apt  to  become  injected.  If  the  infra-orbital  nerve  be  disturbed, 
the  pain  darts  to  the  upper  lip,  to  the  upper  row  of  teeth  and  the 
posterior  nares,  and  the  cheek  reddens  and  tingles,  or  the  eyelids 
twitch.  When  the  pain  occurs  in  the  inferior  branch,  it  radiates 
to  the  lower  lip  and  the  chin,  and  is  frequently  accompanied  by  a 
flow  of  saliva.  Generally  the  parts  around  the  point  where  the 
affected  nerve  emerges  are  sensitive  to  the  slightest  touch.  Some- 
times only  one,  at  other  times  two,  at  others  all  of  the  branches  of 
the  fifth  are  implicated  in  the  complaint,  or  they  may  be  seized 
upon  alternately. 

The  disease  is  one  of  those  belonging  to  advancing  years;  one 
of  the  neuralgias  of  bodily  decay  on  which  Anstie  dwells.     It 


*  Gazette  Hebdom.  de  Med.  et  Chir..  April,  1864;  quoted  in  Ranking's 
Abstract,  vol.  xxxix. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  189 

has  the  same  general  causes  as  any  other  form  of  neuralgia. 
Sometimes  it  is  associated  with  decayed  teeth,  or  with  an  ab- 
normal state  of  the  bones  of  the  head  or  face,  such  as  thicken- 
ing of  the  frontal,  ethmoid,  and  sphenoid  bones.  Many  of  these 
cases  terminate,  after  months  or  years  of  excruciating  agony,  in 
apoplexy.* 

The  intervals  between  the  paroxysms  are  of  very  varying 
length.  They  may  be  of  six  months',  or  even  a  year's,  duration ; 
but  so  long;  an  intermission  is  uncommon.  Seasons  in  which 
sudden  changes  of  weather  are  frequent  generally  excite  several 
attacks  in  those  predisposed  to  them. 

The  malady  is  easily  recognized.  It  may  be  mistaken  for,  or 
rather  there  may  be  mistaken  for  it,  a  disease  of  the  bones  of  the 
face.  But  the  local  signs  of  this  are  different,  and  the  pain  is  not 
paroxysmal.  Painful  anaesthesia  of  the  fifth  nerve  is  discrimi- 
nated by  the  insensibility  of  the  painful  portions  to  the  touch,  or 
indeed  to  any  irritation.  Spasm  of  the  face  is  distinguished  by 
the  absence  of  pain,  from  the  convulsive  twitchings  which  some- 
times take  place  in  tic  douloureux. 

The  epileptiform  neuralgia  described  by  Trousseau  is  dissimilar 
in  these  peculiarities :  whether  simple  or  combined  with  rapid 
convulsive  movements  of  the  muscles  on  one  side  of  the  face,  it  is 
quickly  over ;  it  lasts  but  ten  or  twenty  seconds  at  a  time,  never 
more  than  a  minute.  Yet  during  the  short  duration  of  the 
seizures  the  pain  reaches  an  intensity  greater  than  in  ordinary 
neuralgia.  Moreover,  in  some  persons  who  suffer  from  this 
terrible  malady — the  attacks  of  which  may  happen  in  quick  suc- 
cession by  day  as  well  as  by  night,  and  then  perhaps  remit  for 
weeks  or  months — vertiginous  sensations  or  epileptic  fits  occur, 
and  thus  the  diagnosis  is  facilitated  by  the  history  of  the  case. 

Hemicrania. — As  in  the  other  forms  of  neuralgia,  the  chief 
symptoms  of  the  disorder  resolve  themselves  into  one  symptom, — 
the  symptom  of  pain.  This  is  ordinarily  limited  to  the  supra- 
orbital and  temporal  regions  of  one  side,  but  it  may  extend  to  the 
scalp;  and  in  some  instances  the  cerebral  distress  is  not  one- 
sided, but  double-sided.     The  pain  is  intensified  by  sound  of  any 

*  Sir  Henry  Halford's  Essays  and  Orations,  p.  37  et  seq. 


190  MEDICAL    DIAGNOSIS. 

kind,  and  is  commonly  accompanied  by  a  disorder  of  sight,*  a 
numbness  and  tingling  in  the  limbs,  a  sense  of  weight,  and  more 
or  less  sickness  of  stomach.  Sometimes,  indeed,  the  nausea  and 
vomiting  of  the  "sick-headache"  are  very  prominent  features 
of  the  paroxysm,  hardly  less  prominent  than  the  pain.  The 
attack  lasts  for  hours  or  days;  very  often  it  is  severe  for  half  a 
day.  At  its  termination,  the  patient  feels  exhausted,  yet  soon 
recovers  his  usual  health,  and  may  remain  free  from  a  seizure 
for  a  long  time.  But,  as  the  disorder  most  commonly  occurs  in 
women,  and  usually  at  their  menstrual  periods,  the  interval  is 
not  apt  to  extend  beyond  four  weeks. 

Hemicrania,  or  megrim,  is  a  stubborn  affection.  It  generally 
argues  a  debilitated  state  of  the  system,  and  has  of  late  years  been 
explained  as  a  neurosis  of  the  sympathetic ;  or  as  a  discharge  of 
nerve-force,  a  "nerve-storm,"  from  centric  disorder.  It  is  a  dis- 
ease the  tendency  to  which  diminishes  after  middle  age,  but  which/}" 
as  Liveing  clearly  demonstrates,  has  a  hereditary  character. 

Hemicrania  must  be  carefully  separated  from  the  pain  in  the 
head  which  accompanies  an  organic  cerebral  affection.  The  main 
points  of  distinction  are,  that  the  neuralgic  malady  is  paroxysmal, 
is  attended  with  the  same  group  of  symptoms  during  each  attack, 
and  produces  no  nervous  derangement  in  the  intervals  between 
the  seizures;  while  the  other  morbid  condition  is  more  or  less 
constant,  and  yields  persistent  signs  of  a  cerebral  affection. 

Rheumatism  of  the  scalp  differs  from  hemicrania  in  the  pain 
being  continuous,  dull,  and  superficial ;  in  occupying  generally 
both  sides  of  the  head;  in  being  augmented  by  moving  the 
affected  muscles,  and  relieved  by  warmth.  Moreover,  there  is 
almost  always  other  evidence  of  rheumatism,  and  the  pain  is 
intensified  by  pressure;  whereas  in  hemicrania,  although  the  hair 
may  be  sensitive  to  the  touch,  strong  pressure  on  the  forehead, 
and  even  on  the  hairy  part  of  the  scalp,  does  not  increase  the 
pain,  may  indeed  afford  relief. 

In  jieriostitis  affecting  the  bones  of  the  head,  particularly  when 
occurring  in  connection  with  constitutional  syphilis,  we  may  find 

*  There  may  be  obliteration  of  objects  in  the  field  of  view,  or  a  curious 
glimmering  attended  with  colored  outline  near  the  outside  corner  of  the  field 
of  vision.     See  P.  W.  Latham  "On  Nervous  or  Sick-Headache,"  1873. 

f  On  Megrim,  London,  1873. 


DISEASES    OF    THE    BRAIN    AND    SPINAL    CORD.  191 

the  same  violent  pain  as  in  hemicrania.  But  there  is  considerable 
tenderness  on  pressure,  the  parts  attacked  are  swollen  and  less 
elastic  than  the  healthy  portions,  and  the  pain  is  especially  severe 
at  night. 

Sciatica. — This  is  neuralgia  following  the  course  of  the  sciatic 
nerve.  The  seat  of  the  greatest  suffering  is  generally  the  lateral 
surface  of  the  thigh ;  thence  the  pains  extend  to  the  popliteal 
space,  and  in  some  instances  along  the  anterior  part  of  the  leg. 
Often,  too,  the  patient  complains  of  an  aching  near  the  sciatic 
notch  and  in  the  loins.  The  pain  is  more  or  less  steady,  but  it 
has  its  periods  of  fierce  exacerbation;  and  damp,  cold,  and  press- 
ure augment  it.  Pressure  on  localized  points  always  develops 
pain,  and  the  points  that  are  most  marked  are  on  the  lower 
end  of  the  sacrum,  on  the  side  of  the  trochanter  opposite  the 
emergence  of  the  great  and  small  sciatic  nerves,  various  points  on 
the  posterior  aspect  of  the  thigh,  one  at  the  head  of  the  fibula, 
and  one  behind  the  outer  ankle. 

The  disease  is  obstinate,  and  lasts  for  weeks  or  months.  It 
interferes  with  locomotion,  on  account  of  the  distress  which  move- 
ments of  the  leg  and  foot  occasion.  It  is  rare  in  children,  being 
most  frequent  between  the  ages  of  twenty  and  sixty.*  Generally 
it  depends  upon  cold  or  upon  the  rheumatic  diathesis,  or  upon  a 
neuralgic  predisposition,  or  upon  an  irritation  affecting  the  nerve 
before  it  leaves  the  pelvis,  the  result  not  unusually  of  sexual  dis- 
order, or  of  pressure  from  a  gravid  womb,  or  from  an  accumula- 
tion of  fseces  in  the  colon.  In  some  instances  it  is  connected  with 
gout,  in  others  with  anaemia  or  with  syphilis ;  and  it  may  be, 
although  it  very  rarely  is,  symptomatic  of  cerebral  disease.  Oc- 
casionally it  is  due  to  reflex  excitation  of  the  nerve.  Sometimes 
it  occurs  after  forced  marches  or  long  rides;  probably  in  the 
majority  of  these  cases,  however,  the  sciatica  is  rheumatic. 

Sciatica,  when  of  long  duration,  leads  to  loss  of  motor  power 
in  the  leg  and  to  anaesthesia;  and  certain  nutritive  changes  are 
observed  in  the  limb,  which  is  found  to  have  decidedly  dwindled. 
In  some  instances  the  disorder  is  clearly  the  result  of  neuritis,  and 
then  there  is  generally  more  tenderness;  but,  unless  the  history 


*  Valleix,    Fuller.     Both   of  these   authors   further   state  it   to  be  more 
common  in  men  than  in  women, — which  is  denied  by  Copland  and  Eomberg. 


192  MEDICAL    DIAGNOSIS. 

throw  light  on  the  matter,  it  will  be  very  difficult  to  say  whether 
the  pain  be  from  neuritis  or  not. 

It  is  often  a  very  essential  matter  to  determine  whether  or  not 
an  effusion  has  taken  place  within  the  sheath  of  the  nerve,  since 
it  becomes  of  the  greatest  importance  to  adopt  local  and  general 
means  by  which  the  fluid  can  be  absorbed  before  the  pressure  on 
the  nerve  causes  an  alteration  of  structure.  In  the  main  what 
Fuller  tells  us  is  correct,  that  the  presence  of  fluid  within  the 
nerve-sheath  may  be  inferred  when  a  patient  who  is  suffering 
from  sciatica  complains  of  a  dull  aching  or  a  benumbing  pain  in 
the  limb,  causing  it  to  feel  swollen,  and  this  sense  of  numbness 
and  increased  bulk  has  succeeded  to  pain  of  greater  intensity, 
accompanied  by  cramps  and  startings  and  more  or  less  inability 
to  move  the  limb. 

The  disorders  which  are  most  likely  to  be  confounded  with 
sciatica  are :  rheumatism  of  the  muscles  and  fibrous  sheaths  around 
the  hip-joint;  affections  of  the  joint;  and  pains  caused  by  irrita- 
tion of  the  kidney.  The  former  is  very  readily  distinguished. 
It  is  generally,  what  sciatica  is  rarely,  double-sided  ;  and  the 
pain  is  dull,  diffuse,  not  paroxysmal,  not  limited  to  the  course  of 
the  sciatic  nerve,  nor  as  much  increased  on  pressure  as  that  of 
sciatica.  But,  practically  speaking,  this  kind  of  rheumatism  is 
seldom  seen  unless  associated  with  rheumatic  neuralgia  of  the 
sciatic  nerve. 

In  affections  of  the  hip-joint  the  suffering  is  increased  by  stand- 
ing with  the  weight  of  the  body  thrown  on  the  diseased  leg. 
Moreover,  the  pain  is  usually  limited  to  the  hip-  and  knee-joints; 
the  aspect  of  the  limb  points  to  the  disorganization  that  is  going 
on;  the  leg  shortens.  Yet  before  admitting  this  as  a  mark  of 
difference,  it  must  be  ascertained  by  careful  measurement ;  for,  in 
consequence  of  muscular  contractions,  the  affected  limb  in  sciatica 
may  appear  to  be  shorter  than  it  is.  The  main  points  of  distinc- 
tion between  sciatica  and  the  nervous  affection  of  the  hip-joint 
are  the  usual  combination  of  the  latter  with  hysteria,  the  very 
superficial  tenderness,  and  the  fact  that  the  pain  is  apt  to  extend 
over  the  whole  thigh. 

Irritation  of  the  kidney  causes  pain  shooting  down  the  thigh. 
The  distress  exists,  however,  in  the  course  of  the  anterior  crural 
nerve,  is  therefore  not  localized  in  the  sciatic,  is  unattended  with 


DISEASES    OF    THE    BRAIN    AND    SPINAL    COED.  193 

tenderness,  but  is  accompanied  by  a  frequent  desire  to  pass  water, 
and  by  other  signs  of  disorder  of  the  urinary  functions. 

Sciatica  is  sometimes  feigned,  especially  by  soldiers.  But  the 
copy  is  rarely  a  very  accurate  one.  Impostors  complain  of  pain 
on  pressure  and  on  motion,  but  are  ignorant  that  the  pain  is  prone 
to  exacerbate  after  intervals  of  comparative  quiet,  and  to  increase 
in  violence  as  night  approaches.  Their  fancied  torment  is  con- 
stant, but  does  not  prevent  them  from  sleeping ;  they  wince  when 
the  muscles  of  the  thigh  are  touched,  yet,  if  their  attention  be 
diverted,  the  hand  may  be  pressed  along  the  sciatic  nerve  without 
any  sign  of  tenderness  being  manifested. 


13 


CHAPTER   III. 

DISEASES   OF   THE   UPPER   AIR-PASSAGES. 

The  larynx  and  trachea  form  the  main  portion  of  the  upper 
air-passages.  Let  us  inquire  into  their  affections,  and,  especially 
on  account  of  their  greater  frequency,  into  those  of  the  larynx. 

There  are  several  symptoms  met  with  in  laryngeal  diseases 
which  at  once  direct  attention  to  the  seat  of  the  malady.  The 
larynx  is  the  organ  of  speech :  hence  changes  in  the  voice  con- 
stitute the  most  striking  manifestations  of  laryngeal  disorders. 
These  changes  vary  in  degree.  The  voice  may  be  merely  hoarse, 
or  so  completely  lost  that  the  patient  is  hardly  able  to  speak  in 
an  audible  whisper.  In  young  children  the  different  tone  of  the 
cry  corresponds  to  the  altered  voice  of  adults.  The  alteration  of 
the  voice  depends  almost  wholly  upon  an  affection  of  the  vocal 
cords,  and  this  may  be  organic,  such  as  inflammation,  oedema, 
ulceration,  cicatrices,  and  morbid  growths;  or  it  may  proceed 
from  perverted  or  impaired  innervation.  To  the  latter  class  be- 
long most  of  the  cases  of  "  functional  aphonia."  Very  often  the 
hoarseness  or  loss  of  voice  is  caused  by  diminished  tension  and 
want  of  certain  and  prompt  action  of  the  vocal  cords,  whether 
connected  with  structural  change  or  not.  The  same  cause  gives 
rise,  for  the  most  part,  to  the  modifications  of  the  voice  which 
show  themselves  as  huskiness  in  speaking,  or  in  the  loss  of  certain 
notes  in  singing. 

Next  to  the  voice  in  diagnostic  importance  stand  the  character 
of  the  breathing  and  the  cough. 

The  breathing  is  labored  and  difficult,  and  is  frequently  per- 
ceived to  be  noisy,  and  coarse  or  shrill, — the  so-called  laryngeal 
stridor :  a  sign  encountered  whenever  the  orifice  through  which 
the  air  has  to  pass  is  narrowed,  either  temporarily  by  a  spasm,  or 
more  permanently  by  any  state  which  gives  rise  to  a  constriction 
of  the  parts ;  for  instance,  by  swelling  of  the  mucous  membrane. 
104 


DISEASES   OF   THE   UPPER   AIR-PASSAGES.  195 

The  difficulty  in  breathing  is  in  some  diseases  slight ;  in  others 
great.  One  of  the  peculiarities  of  this  laryngeal  dyspnoea  is  its 
tendency  to  recur  in  paroxysms,  during  which  the  patient  appears 
to  be  in  imminent  danger  of  strangling.  These  fits  of  suffocation 
are  produced  mostly  by  a  spasm  of  the  glottis.  They  occur  in 
pure  spasm  of  the  glottis ;  in  croup ;  in  oedema  of  the  glottis ;  in 
ulceration  and  in  polypi  of  the  larynx. 

The  cough  of  laryngeal  affections  presents  frequently  the  same 
peculiarity  as  the  dyspnoea, — it  happens  in  paroxysms.  Another 
peculiarity,  although  not  one  so  constant,  is  its  harsh  and  ring- 
ing tone.  The  cough  is  often  short  and  dry;  sometimes  it  is 
followed  by  a  muco-purulent  expectoration  of  roundish  shape,  or 
by  a  blood-streaked  sputum,  or,  as  in  pseudomembranous  laryn- 
gitis, by  the  spitting  up  of  false  membrane.  It  is  readily  excited 
by  the  act  of  swallowing,  and  its  seat  is  referred  by  the  patient 
himself  to  the  windpipe. 

Pain  is  not  so  usual  a  symptom  of  laryngeal  disease  as  either 
cough  or  changed  breathing.  In  chronic  affections  it  may  be, 
indeed,  wanting.  It  is  rarely  severe ;  often  more  a  sensation  of 
tickling,  of  burning,  or  of  uneasiness  than  of  actual  pain.  It  is 
apt  to  extend  down  the  trachea  to  the  upper  part  of  the  sternum. 
Sometimes  it  is  increased  on  pressure,  as  in  acute  laryngitis  and 
in  ulceration  of  the  mucous  membrane ;  and  it  may  be  also  aug- 
mented by  the  act  of  swallowing. 

By  the  symptoms,  then,  of  altered  voice,  cough,  dyspnoea, 
and,  in  some  cases,  of  local  pain  and  difficulty  in  deglutition, 
we  recognize  a  laryngeal  affection ;  and  these  symptoms  reveal 
more  than  any  physical  examination  of  the  organ  made  by  the 
means  ordinarily  in  use.  The  stethoscope  is  occasionally  of  ser- 
vice ;  yet,  on  the  whole,  it  furnishes  little  information.  But, 
of  late  years,  inspection  of  the  larynx  has  been  rendered  prac- 
ticable by  the  aid  of  an  ingenious  instrument,  the  laryngoscope, 
and  our  knowledge  of  laryngeal  diseases  has  already  been  revo- 
lutionized through  its  influence.  The  instrument  introduced  by 
Czermak — the  physician  to  whom  we  are  chiefly  indebted  for 
the  information  gained  by  the  application  of  laryngoscopy  to  dis- 
ease— is  a  modification  of  the  one  used  by  Garcia  in  his  researches 
on  the  human  voice.  It  consists  of  a  small  mirror  fixed  on  a 
Ion o;  stem. 


196 


MEDICAL    DIAGNOSIS. 


The  mirror  is  best  made  of 
glass  backed  with  silver  or 
with  amalgam.  It  may  be 
either  circular,  square,  or  oval. 
The  circular  mirror  occasions 
least  irritation.  It  may  vary- 
in  size  from  half  an  inch  to  an 
inch  and  a  quarter  in  diam- 
eter. The  larger  the  mirror 
we  can  employ,  the  better  is 
the  image. 

The  mirror  is  in  some  cases 
all  that  is  necessary  to  practise 
laryngoscopy.    It  is  heated  in 
warm  water  or  over  a  spirit-lamp,  and 
then    introduced    into    the   back  of   the 
mouth  in  the  manner  presently  to  be  de- 
scribed ;  the  person  to  be  examined  having 
been    placed   with    his   face   toward    the 
sunlight,  so  that  its  rays  may  strike  the 
laryngeal  mirror. 

But  examinations  by  direct  light  are 
practicable  only  on  some  days  and  at 
certain  periods  of  the  day.  Usually  we 
require  a  second  mirror  to  illuminate  the 
throat  and  the  laryngoscope.  This  mir- 
ror, when  sunlight  is  employed,  has  a 
plane  surface;  when  artificial  light  is 
used,  it  is  better  that  the  reflector  be 
slightly  concave.  One  of  circular  form, 
about  three  inches  and  a  half  in  diam- 
eter, and  with  a  focus  of  from  ten  to 
fourteen  inches,  answers  best.  It  may 
be  either  attached  to  the  head  by  means 
of  a  band,  or  worn  on  a  pair  of  spectacle- 
frames,  or  placed  on  a  movable  stand,  or 
affixed  to  a  lamp,  or  fastened  to  a  handle 
which  is  held  in  the  mouth.  The  latter 
plan,  that  of  Czermak,  is  the  one  least 
employed ;  it  is  far  less  convenient  than 


Fig.  8. 


Laryngoscopes  of  various  sli 
not  quite  natural  size. 


DISEASES   OF  THE   UPPER   AIR-PASSAGES.  197 

the  spectacle  attachment  introduced  by  Semeleder.*  When  this 
or  the  frontal  band  is  made  use  of,  the  observer  may  either  place 
the  mirror  opposite  to  one  of  his  eyes,  and  look  through  the  cen- 
tral perforation,  or  adopt  the  easier  method  of  wearing  the  reflector 
on  his  forehead. 

Still  another  way  of  obtaining  a  strong  illumination  of  the  fauces 
is  by  means  of  a  globe  of  glass  filled  with  water,  as  recommended 
by  Stoerck  and  Walker.  The  French,  following  the  lead  of 
Moura,f  have  recourse  for  the  most  part  to  lenses,  and  concentrate 
the  light  directly  into  the  throat.  The  lamp  which  I  formerly 
often  employed  has  a  movable  arm  with  a  concave  reflector  at- 
tached to  its  free  end,  and  by  means  of  a  bull's-eye  condenser  light 
is  first  thrown  on  the  reflector  and  thence  into  the  mouth.  But  a 
better  arrangement  is  obtained  in  Mackenzie's  rack-movement 
bracket  and  bull's-eye  condenser,  or  by  a  combination  of  lenses 
attached  to  a  metallic  frame,  which  is  fastened  to  a  lamp,  as  in 
the  well-known  apparatus  of  Tobold.  The  best  light  to  employ 
is  coal-oil ;  the  most  convenient,  an  argand  gas-burner. 

Supposing  that  we  wish  to  examine  the  larynx  with  the  usual 
instruments,  and  by  artificial  light,  we  should  proceed  thus. 
The  patient,  sitting  in  an  upright  position,  with  his  head  slightly 
inclined  backward,  is  placed  near  a  petroleum-  or  gas-lamp,  burn- 
ing with  a  steady,  brilliant  light,  and  the  flame  of  which  is' behind 
and  about  on  a  level  with  his  eyes.  He  is  directed  to  open  his 
mouth  widely,  to  put  out  his  tongue,  and  to  hold  between  two 
fingers  its  point  enveloped  in  a  soft  napkin  or  handkerchief.  If 
he  cannot  accomplish  this  readily,  the  observer  must  hold  the  pro- 
truded tongue,  or  a  tongue-depressor  must  be  employed.  The 
observer  now  seats  himself  directly  in  front  of  the  patient,  and 
nearly  a  foot  from  the  mouth.  Putting  on  his  spectacles  or 
frontal  band,  he  throws  a  disk  of  light  into  the  back  part  of  the 
mouth ;  he  then  rapidly  introduces  the  laryngeal  mirror,  previ- 
ously heated  in  warm  water  or  over  a  lamp  and  its  proper  tem- 
perature ascertained  by  touching  his  own  hand  or  cheek.  The 
mirror,  great  care  being  taken  not  to  bring  it  in  contact  with 
the  tongue,  is  placed  with  its  back  against  the  uvula,  which, 


*  Khinoscopy  and  Laryngoscopy,  trans.,  New  York,  1866. 
f  Traite  pratique  de  Laryngoscopie,  Paris,  1864. 


198 


MEDICAL    DIAGNOSIS. 


with  the  soft  palate,  is  pressed  backward  and  upward ;  the  lower 
surface  of  the  laryngoscope  should  be  firmly  applied  to,  or,  if  this 
be  found  to  occasion  too  much  irritation,  should  be  held  near,  the 
posterior  wall  of  the  pharynx.  The  inclination  of  the  mirror 
varies  with  the  position  of  the  patient  and  the  parts  we  wish  more 

Fig.  9. 


Laryngoscopy;  examination,  as  made  with  the  means  ordinarily  employed, 

particularly  to  explore.     As  a  general  rule,  it  may  rest  at  an  angle 
of  about  45°. 

This  is  the  manner  in  which  an  examination  is  made  when 
the  reflector  is  worn  by  the  examiner.  "When  the  mirror  is  sta- 
tionary, as  for  instance  in  the  Tobold  laryngoscopic  lamp, — a  less 
portable  but  far  easier  mode  of  illuminating, — the  reflector  is 
attached  to  the  lamp  by  a  freely  movable  brass  rod,  and  the  light  is 
thus  thrown  into  the  mouth,  leaving  the  examiner  unembarrassed. 
When  the  mirror  has  been  introduced  in  the  manner  described, 


DISEASES   OF   THE   UPPER   AIR-PASSAGES. 


199 


Lar}Tngeal  image,  as  seen  in  the  laryngoscope 
under  favorable  circumstances. 


the.  laryngeal  image  is  readily  perceived.  We  see  the  epiglottis, 
the  glottis,  the  cartilages,  the  true  vocal  cords,  the  superior  thyro- 
arytenoid ligaments  or  false  vocal  cords,  and  in  some  cases  even 
the  rings  of  the  trachea.  We  may  be  able  to  discern  each  portion 
of  the  laryngeal  aperture  with  distinctness,  or  it  may  take  several 
examinations  to  do  so. 

In  health,  the  color  of  the 
various  parts  is  very  different. 
Stoerck  has  well  described  it  in 
likening  that  of  the  epiglottis, 
the  interior  of  the  larynx  below 
the  glottis,  and  of  the  cricoid 
cartilage,  to  the  coloration  of  the 
conjunctiva  of  the  eyelid ;  and 
the  hue  of  the  aryepiglottidean 
folds  and  the  prominences  of  the 
arytenoid  cartilages  to  that  of 
the  gums.  The  mucous  mem- 
brane of  the  trachea  between  the  rings  is  of  a  pale  pink  color; 
the  vocal  cords  have  a  white,  glistening  look.  Mackenzie  takes 
special  notice  of  the  whole  of  the  under  surface  of  the  epiglottis 
being  in  some  cases  of  a  bright-red  hue;  and  Gibb  points  out  that 
in  negroes  the  cartilages  of  Wrisberg  have  a  yellowish  tinge. 

The  laryngeal  image  in  the  mirror  bears  this  relation  to  the 
real  position  of  the  parts :  the  right  vocal  cord  of  the  person  who 
is  examined  is  seen  on  the  left  side  of  the  mirror,  and  the  left 
vocal  cord  on  the  right;  or,  to  state  the  matter  in  a  form  easily  to 
be  remembered,  the  cord  which  corresponds  to  the  right  hand  of 
the  patient  is  the  right,  that  seen  toward  his  left  hand  is  the  left. 
The  epiglottis  appears  in  the  laryngoscope  at  the  upper  portion 
and  behind ;  so  do  the  other  structures  which  lie  in  front.  The 
arytenoid  cartilages  appear  at  its  lower  portion,  and  toward  the 
front. 

To  judge  of  the  movements  of  the  vocal  cords,  we  tell  the 
patient  alternately  to  inspire  deeply  and  to  sound,  as  a  high  note, 
a  sound  like  "ah."  During  this  the  vocal  cords  are  closely 
approximated  and  stretched,  and  the  epiglottis,  in  fact  the  whole 
larynx,  is  elevated;  while  during  a  full  inspiration  the  cords  are 
far  apart,  and  hence  the  glottis  is  wide  open.     To  obtain  a  satis- 


200  MEDICAL,    DIAGNOSIS. 

factory  sight  of  the  deeper-seated  parts,  we  must  bear  in  mind 
that  the  more  the  surface  of  the  mirror  is  placed  horizontally, 
the  more  distinctly  they  come  into  view.  For  the  exploration  of 
these  structures,  and  particularly  of  the  trachea,  the  light  must  be 
thrown  from  below  upward  upon  the  laryngoscope. 

In  some  patients  laryngoscopy  is  easy ;  the  instrument  causes 
no  irritation,  and  a  conclusive  examination  may  be  made  at  the 
first  attempt.  In  others,  a  course  of  training  is  required  to  subdue 
the  sensibility  of  the  fauces,  which  may  be  general,  or  be  limited 
to  a  very  small  spot.  As  a  means  of  overcoming  the  difficulty, 
sucking  small  pieces  of  ice,  or  the  previous  administration  of 
bromide  of  potassium,  has  been  recommended.  But  the  best 
means  is  skill  in  the  use  of  the  instrument, — its  rapid  and  de- 
cisive handling. 

In  some  persons  with  very  irritable  throats,  I  have  obtained 
good  views  by  pressing  the  instrument  against  the  roof  of  the 
mouth,  instead  of  passing  it  back  into  the  pharynx,  and  by  alter- 
ing the  position  of  the  head  a  little,  tilting  it  more  backward. 
The  epiglottis,  and  the  structures  at  the  entrance  of  the  windpipe, 
are  thus  readily  enough  brought  into  view ;  with  the  deeper  parts 
we  do  not  succeed  so  well.  But  in  many  cases  we  get  sufficient 
guide  for  topical  applications. 

There  are  some  further  obstacles,  such  as  a  rising  up  of  the 
tongue,  greatly-enlarged  tonsils,  a  very  long  uvula,  or  a  pendent 
epiglottis,  all  of  which  at  times  seriously  interfere  with  our  inves- 
tigations. But  in  any  case  we  should  not  endeavor  to  make  the 
view  more  satisfactory  by  constantly  altering  the  position  of  the 
mirror.  It  is  always  better  to  introduce  it  repeatedly,  than  to 
shift  it  often  when  introduced,  or  to  keep  it  for  any  length  of 
time  in  the  patient's  mouth. 

To  acquire  dexterity  and  quickness  of  manipulation,  one  of  the 
best  means  in  our  possession  is  autolaryngoscopy.  We  may  readily 
inspect  our  own  larynx  by  the  simple  method  recommended  by 
George  Johnson,*  of  employing  a  toilet-glass  and  throwing  the 
light,  with  the  reflector  worn  in  the  ordinary  manner,  on  the  image 
of  the  fauces  as  seen  in  the  toilet-glass;  the  laryngeal  mirror  is 
then  introduced  into  the  mouth. 

*  Lectures  on  the  Laryngoscope. 


DISEASES   OF   THE   UPPER  AIR-PASSAGES.  201 

If  the  mirror  be  passed  behind  the  uvula,  and  the  reflecting 
surface  directed  upward,  the  posterior  nares  niay  be  examined. 
To  practise  rhinoscopy,  however,  the  mirror  should  be  small  and 
fixed  to  the  shaft  at  a  right  angle.  The  patient  is  directed  to  keep 
his  head  erect,  or  bend  it  slightly  forward,  and  while  his  mouth  is 
widely  open  a  strong  light  is  thrown  to  the  back  of  the  throat. 
But  before  the  rhinal  mirror  is  placed  in  position,  a  tongue-spatula 
is  applied,  with  which  the  back  of  the  tongue  is  well  pressed 
down.  After  the  spatula  has  been  suitably  fixed,  it  is  given  to  the 
patient  to  hold.  It  is  rarely  that  we  can  dispense  with  the  use  of 
the  spatula,  though  we  may  do  so  by  employing,  as  recommended 
by  Voltolini,  a  shield  of  gutta-percha,  a  part  of  which  is  raised 
up  to  allow  the  handle  of  the  mirror  to  pass  through.  Yet, 
whether  the  spatula  be  employed  or  not,  a  difficulty  still  remains, 
— namely,  to  get  the  uvula  out  of  the  way.  This  is  not  easily 
accomplished  without  a  palate-hook,  by  which  means  the  uvula, 
with  a  portion  of  the  soft  palate,  is  gently  drawn  forward  and 
upward,  the  handle  of  the  hook,  being  held  to  one  side  of  the 
mouth  :  Voltolini's*  new  palate-hook  widens  the  pharyngo-nasal 
space  very  satisfactorily.  The  mirror,  with  its  reflecting  surface 
toward  the  operator,  is  now  passed  along  the  spatula,  until  it 
reaches  the  posterior  wall  of  the  pharynx.  By  then  raising  some- 
what the  handle  of  the  mirror,  we  obtain  a  view  of  the  septum; 
and  by  slanting  the  mirror  first  toward  one  side  and  then  toward 
the  other,  the  posterior  nares  and  the  orifices  of  the  Eustachian 
tubes  may  be  inspected. 

The  art  of  rhinoscopy  is  more  difficult  than  that  of  laryn- 
goscopy, and  demands,  to  acquire  proficiency,  constant  practice. 
Though  the  rhinal  mirror  aids  us  in  detecting  morbid  appearances 
which  would  otherwise  escape  observation,  it  does  so  neither  as 
readily  nor  as  completely  as  the  laryngoscope.  By  the  aid  of  this 
we  can  discern  inflammation  of  various  parts  of  the  larynx; 
oedema ;  ulcers ;  cicatrices ;  excrescences  and  morbid  growths ; 
irregularities  in  the  shape  of  the  glottis  and  in  the  mobility  of  the 
cords;  palsies  of  individual  muscles;  abscesses;  diseases  of  the 
cartilages ;  and  other  abnormal  conditions  which,  without  it,  could 
not  be  recognized,  or,  to  say  the  least,  could  not  be  discriminated 

*  Die  Rhinoscopie  und  Pharyngoscopie,  1879. 


202  MEDICAL    DIAGNOSIS. 

with  any  degree  of  certainty.  Indeed,  any  one  who  attempts  a 
positive  diagnosis  of  laryngeal  diseases  without  the  laryngoscope 
attempts  to  do  without  the  only  means  which  renders  the  diagnosis 
at  all  trustworthy,  and  is  guilty  of  neglect. 

Let  us  now  look  at  the  chief  diseases  of  the  larynx.  Grouped 
in  accordance  with  their  main  features,  and  without  classifying 
them  in  strict  obedience  to  laryngoscopic  inquiries,  they  may  be 
arranged  as  follows : 

Act'TE  Organic  Diseases. 

Inflammation  of  the  mucous  membrane  of  the  larynx — Acute  laryngitis. 
(Edema  of  the  glottis. 

Acute  affections  of  the  larynx -»  Q  ,.         ,  ,  ,  ,  ... 

Spasmodic  and  pseudomembranous  laryngitis 
and  trachea  as  met  with  ?■-,,,  , 

— .raise  and  true  croup, 
in  children.  J 

Chronic  Organic  Diseases. 

Inflammation  of  the  mucous  membrane  of  a  part,  or  of  the  whole— Chronic 

laryngitis  in  its  various  forms. 
Destruction  of  the  cartilages. 
Growths  and  tumors  of  various  kinds. 
Ulcers,  simple  and  specific. 

Affections  of  the  Nerves. 

Spasm  of  the  glottis.     (Laryngismus  stridulus.) 

„  i       •      f  Functional,  or  purely  nervous  aphonia. 

.>  ervous  aphonia.  <  ^      ,     .      '  ,        „    ,  , 

I  Paralysis  of  the  muscles  of  the  cord. 

Acute  Laryngeal  Affections. 

Acute  Laryngitis. — In  its  mild  form,  acute  laryngitis  is 
neither  an  uncommon  nor  a  dangerous  disease.  In  its  severer 
form  it  is  much  more  uncommon,  and  very  much  more  dangerous. 
The  inflammation  attacks,  in  either  case,  the  mucous  membrane 
lining  the  cartilages.  "When  it  is  slight,  it  occasions  simply 
hoarseness ;  a  feeling  of  tickling  and  irritation  in  or  near  the 
larynx;  a  trifling,  though  annoying,  cough,  or  rather  a  constant 
disposition  to  clear  the  throat,  more  than  a  cough;  and,  owing  in 
a  great  measure  to  a  coexisting  inflammation  of  the  fauces,  some 
difficulty  in  swallowing.  This  is  one  of  the  forms  of  the  "  bad 
sore-throat"  so  frequently  seen  in  winter  and  in  the  early  months 
of  spring,  which  passes  off  in  the  course  of  a  few  days. 


DISEASES   OF   THE    UPPER   AIR-PASSAGES.  203 

"When  the  inflammation  is  violent,  and  especially  when  it  in- 
volves the  submucous  tissues,  the  symptoms  are  much  aggravated, 
and  the  patient's  life  is  in  imminent  peril.  His  suffering  is 
great ;  for  the  swollen  membrane  nearly  closes  the  narrow  aper- 
ture through  which  the  air  reaches  the  lungs.  His  respiration 
becomes  seriously  impeded,  he  breathes  often,  and  each  time  he 
draws  his  breath  a  wheezing  or  whistling  noise  is  heard.  He 
coughs  frequently,  yet  expectorates  little;  and  the  cough  is  dis- 
tressing and  painful,  and  has  a  harsh  sound.  The  voice  is  hoarse, 
or  sinks  into  a  scarcely  audible  whisper.  The  patient  knows 
the  seat  of  his  disease:  he  feels  that  it  lies  in  the  windpipe,  and 
complains  of  this  being  tender  when  pressed,  and  of  a  feeling  of 
constriction  in  the  throat.  There  is  trouble  in  swallowing,  and 
fever,  with  a  full  pulse  and  flushed  face.  If  the  case  advance 
unchecked,  the  countenance  becomes  distressed  and  pale,  the  lips 
bluish,  the  pulse  irregular,  and  death  sets  in  with  all  the  signs  of 
deficient  aeration  of  the  blood  and  of  strangulation. 

The  disease  in  its  graver  form  runs  a  very  rapid  course.  If  in 
a  few  days  after  its  commencement  no  improvement  show  itself, 
life  does  not  last  long.  Sometimes  death  takes  place  on  the  first 
day  of  the  attack.     It  rarely  waits  for  the  sixth. 

Acute  idiopathic  laryngitis  is  seldom  met  with  save  in  adults. 
Children  suffer  from  an  analogous  but  not  an  identical  disease, 
croup.  Occasionally  we  do  see  acute  laryngitis  in  children,  and 
exhibiting  the  same  features  as  in  the  adult;  but  then  it  has 
almost  always  arisen  as  the  consequence  of  swallowing  irritating 
substances,  and  not  as  the  result  of  exposure  to  cold  or  wet. 

The  marked  symptoms  of  the  perilous  complaint  prevent  it 
from  being  overlooked,  and  render  its  discrimination  easy.  There 
is  fever  with  dyspnoea  in  the  acute  pulmonary  affections ;  but  the 
voice  remains  unaltered,  and  they  exhibit  physical  signs  which 
acute  laryngitis  does  not, — they  show  rales,  or  abnormal  respira- 
tion-sounds; while  in  laryngitis  the  murmur  of  the  lungs  is  that 
of  health,  although  it  is  sometimes  enfeebled  by  the  impediment  in 
breathing,  or  obscured  by  the  shrill  sound  which  issues  from  the 
larynx.  We  find  difficulty  in  swallowing  and  some  hinderance  in 
breathing  in  tonsillitis;  but  inspection  of  the  oral  cavity  imme- 
diately detects  the  source  of  the  disorder.  There  is  difficulty  in 
swallowing  in  pharyngitis,  but  there  is  not  embarrassed  breathing, 


204  MEDICAL    DIAGNOSIS. 

or  a  peculiar  voice,  or  cough,  and  the  fauces  appear  dusky  and 
injected,  while  they  are  but  slightly  affected  in  laryngitis,  unless 
the  inflammation  of  the  larynx  have  supervened  upon  that  of  the 
throat.  Croup  resembles  acute  idiopathic  laryngitis  most  nearly; 
but  it  is  as  rare  in  the  adult  as  acute  laryngitis  is  in  the  child, 
and,  as  we  shall  presently  see,  obvious  differences  in  the  symptoms 
exist. 

There  is  a  peculiar  form  of  inflammation  of  the  larynx,  diffuse 
cellular  laryngitis,  a  diffuse  inflammation  of  the  cellular  tissue, 
with  lymph  or  pus  infiltrated  in  the  submucous  tissue,  to  which 
attention  has  been  called  by  Henry  Gray.*  It  is  a  formidable 
affection,  which  bears  a  strong  likeness  to  erysipelatous  laryngitis, 
but,  what  is  not  by  any  means  constantly  the  case  in  this  disorder, 
the  symptoms  begin  in  the  fauces  and  larynx ;  and,  wholly  unlike 
erysipelatous  laryngitis,  the  submucous  tissue  is  primarily  attacked, 
and  the  neck  becomes  greatly  swollen  from  the  effused  products 
around  the  larynx,  trachea,  and  oesophagus  filling  its  cellular 
tissue.  The  disease  begins  with  chills,  soreness  of  throat,  and  fever, 
soon  succeeded  by  a  hacking  cough,  by  dyspnoea,  by  a  dusky  hue 
of  the  fauces,  by  enlargement  of  the  tonsils  and  of  the  glands  in 
the  neighborhood  of  the  jaw,  and  by  great  difficulty  in  swallowing. 
As  the  complaint  proceeds,  the  neck  increases  greatly  in  size,  the 
fever  assumes  a  low  type,  and  the  patient  either  sinks  gradually 
or  dies  asphyxiated,  perishing  sometimes  rapidly  from  a  speedy 
increase  of  the  laryngeal  oedema. 

(Edema  of  the  Glottis. — The  danger  of  acute  laryngitis  of 
any  kind  is  much  aggravated  by  the  precise  seat  of  the  disease. 
When  the  inflammation  takes  place  immediately  around  the  glottis, 
and  causes  a  serous  fluid  to  transude,  the  peril  is  greatly  increased. 
The  inspiration  is  audible,  noisy,  hissing,  and  labored ;  there  is  a 
distressing  sensation  of  constriction  or  obstruction  in  the  wind- 
pipe, and  the  patient  makes  repeated  efforts,  by  swallowing  or  by 
hawking,  to  clear  his  throat  of  the  substance  which  seems  to  be 
clogging  it.  His  difficulty  of  breathing  is  intense,  and  occurs 
in  frightful  paroxysms,  sometimes  of  a  quarter  of  an  hour  in  dura- 
tion, during  the  whole  of  which  time  strangulation  appears  to  be 
imminent;  and  often  he  does  perish  by  strangulation. 

*  Holmes's  System  of  Surgery,  vol.  iv. 


DISEASES    OF   THE    UPPER   AIR-PASSAGES.  205 

This  grave  form  of  cedema  of  the  glottis  sometimes  follows  an 
extension  of  the  peculiar  inflammation  of  the  throat  in  the  ex- 
anthemata, or  is  of  erysipelatous  origin,  and  it  occasions  death 
quickly,  and  amid  great  suffering.  But  the  cedema  may  arise 
without  preceding  acute  inflammation,  whether  this  be  specific  or 
not.  It  may  result  from  long-continued  pressure  on  the  trachea 
or  larynx,  or  occur  in  connection  with  the  external  oedema  of 
Bn'ght's  disease.  Again,  an  effusion  of  serum  may  cause  death 
most  suddenly  and  unexpectedly  in  a  person  who  has  been  labor- 
ing under  a  chronic  laryngeal  disorder.  Such  cases  of  oedema  of 
the  glottis  are  distinguished  from  those  produced  by  active  laryn- 
geal inflammation  by  the  absence  of  fever,  of  local  tenderness, 
and  of  marked  difficulty  of  deglutition.  It  is  true  that,  if  the 
cedematous  affection  ensue  upon  a  chronic  inflammation  of  the 
larynx,  tenderness  and  an  impediment  to  swallowing  may  be 
observed.  But  the  history  of  the  malady  and  the  non-existence 
of  fever  leave  little  room  for  error. 

The  diagnostic  sign  which  some  have  proposed  as  the  proof  of 
the  presence  of  cedema  of  the  glottis — the  swelling  of  the  epi- 
glottis, as  ascertained  by  the  touch — cannot  be  relied  upon, 
because  this  swelling  does  not  always  exist  to  an  obvious  degree, 
and,  even  when  it  does  exist,  is  not  readily  determined  by  the 
finger. 

Croup. — Croup  is  inflammation  of  the  larynx  and  trachea;  but 
it  is  something  more.  It  is  a  spasmodic  action  of  the  muscles  of 
the  larynx,  which  spasmodic  action  gives  rise  to  much  of  the 
peculiar  cough,  the  stridor,  and  the  paroxysms  of  dyspnoea,  so 
characteristic  of  the  disease.  As  croup  is  thus  an  affection  com- 
posed, as  it  were,  of  several  distinct  elements,  it  differs  somewhat 
according  as  one  or  the  other  of  these  elements  preponderates. 
Thus,  the  inflammation  may  be  comparatively  slight,  yet  the 
spasm  play  a  very  prominent  part;  or  the  inflammation  may  be 
very  severe,  and  result  in  the  formation  of  a  false  membrane. 
To  the  first  class  belongs  the  disorder  known  as  false  croup, 
catarrhal  croup,  striclulous  laryngitis,  spasmodic  laryngitis;  to  the 
second,  the  true  croup,  membranous  croup,  or  pseudomembranous 
laryngitis. 

False  or  catarrhal  croup. — This  is  one  of  the  common  diseases 
of  childhood.     Its  seizures  happen  chiefly  at  night;  and  the  child 


206  MEDICAL    DIAGNOSIS. 

that  has  gone  to  bed  well,  or  perhaps  fretful  from  teething,  or 
with  a  slight  catarrh,  wakes  up  suddenly  in  a  state  of  alarm, 
breathing  with  difficulty.  It  coughs  with  violence  and  at  short 
intervals,  and  the  cough  is  noticed  to  be  loud  and  ringing  and 
hoarse;  and  so  are  the  voice  and  the  cry.  Each  inspiration  is 
attended  with  that  shrill,  "croupy"  sound  which,  once  heard,  is 
never  forgotten.  The  face  is  flushed,  the  pulse  frequent,  and  the 
skin  hot,  or,  to  speak  more  accurately,  heated,  for,  in  the  majority 
of  cases,  the  fever  is  not  of  active  character.  The  paroxysm  con- 
tinues in  this  manner  for  about  an  hour;  the  breathing  then  be- 
comes quiet,  the  child  falls  asleep,  and  rests  well  until  toward 
morning,  when  the  attack  is  apt  to  be  renewed.  The  little 
patient  may,  however,  escape  this  altogether,  and  keep  well ; 
or  else  the  paroxysm  recurs  the  next  night,  or  for  several  nights 
in  succession.  In  the  intervals  the  voice  and  respiration  are 
natural,  there  is  little  or  no  fever,  little  or  no  cough.  Yet  some- 
times a  cough  remains,  which  has  every  now  and  then  a  croupal 
sound ;  the  voice,  too,  is  slightly  hoarse,  but  not  smothered  or 
extinct,  as  in  true  croup. 

False  croup  most  frequently  follows  exposure.  It  is  very  rarely 
fatal ;  hence  we  are  not  conversant  with  its  morbid  anatomy.  The 
few  cases  which  have  been  examined  presented  signs  of  inflamma- 
tion in  the  larynx  and  trachea,  inadequate,  however,  in  themselves 
to  account  for  death.  Yet  such  inflammation  probably  always 
exists  to  a  greater  or  less  degree.  Cases  in  which  it  is  extensive 
and  severe,  without  having  led  to  a  plastic  exudation,  approach 
in  their  persistency  and  in  the  character  of  their  symptoms  closely 
to  true  croup.  Indeed,  one  form  of  the  complaint  may  run  into 
the  other,  which  is  far  from  astonishing,  since  they  are  not  two 
diseases,  but  only  two  forms  of  the  same  disease. 

The  main  element  in  the  production  of  the  symptoms  of  false 
croup  is  undoubtedly  spasm  of  the  glottis;  and  this  is  the  reason 
why  this  affection  is  so  often  described  as  identical  with  the  first- 
named  malady.  But,  without  entering  into  the  much-vexed 
questions  of  pathology;  without  discussing  whether  or  not  the 
laryngismus  stridulus,  as  spasm  of  the  glottis  is  called  by  many, 
is  due  to  enlargement  of  the  thymus  gland,  or  of  the  cervical  and 
bronchial  glands  ;  whether  or  not  it  is  caused  by  an  organic  dis- 
ease of  the  cerebro-spinal  axis,  or  is  simply  a  reflex  phenomenon, 


DISEASES    OF    THE    UPPER   AIE-PASSAGES.  207 

— it  seems  undoubted  that  the  spasm,  while  it  may  complicate  any 
affection  of  the  larynx  and  trachea,  may  also  exist  independently. 
It  may,  therefore,  form  a  distinct  disorder,  which  differs  from 
false  croup  by  the  absence  of  all  inflammation  and  by  several 
circumstances  which  proclaim  its  non-identity,  such  as  its  occur- 
rence in  adults  as  well  as  in  children,  and  its  frequent  association 
with  other  convulsive  symptoms, — with  distortion  of  the  face, 
spasmodic  contraction  of  the  hands  and  feet,  and  general  con- 
vulsions. 

As  in  croup,  the  seizures  are  apt  to  take  place  at  night.  Gen- 
erally the  child  has  been  fretful  from  teething,  or  from  gastric  or 
intestinal  irritation,  when  suddenly  an  attack  of  difficult  breathing 
occurs,  accompanied  by  several  loud,  crowing  inspirations,  and 
by  an  appearance  of  the  most  manifest  distress  and  of  threaten- 
ing suffocation;  yet  the  paroxysm  is  not  associated  either  with 
cough,  or  with  fever,  or  with  an  altered  voice  or  a  materially 
changed  cry.  A  fit  of  this  kind  may  be  repeated  twenty  or  thirty 
times  a  day.  It  may  terminate  fatally  in  a  short  time ;  usually, 
however,  the  paroxysms  are  spread  over  weeks,  or  even  over  a 
longer  period.  Thus,  in  addition  to  the  frequent  combination 
with  other  convulsive  symptoms,  the  protracted  duration  of  the 
disease,  and  the  absence  of  febrile  disturbance,  of  hoarseness,  and 
of  cough,  point  out  the  distinction  between  spasm  of  the  glottis 
and  spasmodic  laryngitis.  In  laryngismus  stridulus,  too,  as 
Squire  has  told  us,  low  temperature  will  exclude  the  complication 
of  laryngitis.* 

True  or  membranous  croup. — True  croup  is  a  formidable  affec- 
tion, in  which  there  is  not  only  inflammation,  but  inflammation 
which  results  in  the  formation  of  a  false  membrane.  The  plastic 
exudation  is  found  lining  the  larynx,  extending  into  the  trachea 
or  down  into  the  bronchial  tubes,  and  is  seen  in  the  fauces  and  on 
the  tonsils. 

The  symptoms  of  this  dangerous  malady  are :  the  same  brazen 
cough,  the  same  stridulous  breathing,  as  in  false  croup;  a  de- 
cided change  in  the  voice,  dyspnoea,  and  fever.  But  all  these 
symptoms  do  not  show  themselves  at  once.  The  disease  usually 
begins  with,  or  rather  is  preceded  by,  slight  fever  and  catarrh, 

*  Transactions  of  the  Obstetrical  Society  of  London,  vol.  xii. 


208  MEDICAL    DIAGNOSIS. 

and  some  hoarseness.  This  may  last  for  a  few  days,  when  the 
symptoms  peculiar  to  croup  manifest  themselves.  The  cough 
attracts  attention  by  its  ringing  sound,  and  at  the  same  time,  or 
shortly  after,  the  characteristic  croupal  respiration  is  perceived. 
High  fever  and  difficulty  in  breathing  soon  set  in,  and,  although 
they  exacerbate  and  remit,  only  cease  when  the  disease  ceases. 
There  is  much  thirst,  no  appetite;  but  what  is  taken  is  readily 
enough  swallowed.  The  voice  is  changed  almost  from  the  onset. 
It  is  hoarse  and  whispering,  and,  as  the  disease  advances,  often 
becomes  totally  suppressed. 

The  child  remains  in  this  condition  for  several  days :  restless, 
with  its  head  thrown  back,  its  respiration  labored,  and  the  croupal 
sound  never  completely  disappearing.  Sometimes,  but  far  from 
always,  solid  masses  of  membrane  are  coughed  up.  Finally,  the 
cough  stops  altogether ;  the  intervals  between  the  paroxysms  of 
dyspnoea  are  effaced ;  the  countenance  becomes  livid ;  the  skin  loses 
its  sensibility ;  the  extremities  grow  cold ;  and,  unless  relief  be 
afforded,  either  by  medicinal  means  or  by  an  operation,  the  little 
sufferer  dies  comatose  or  suffocated.  The  fatal  termination  is  not 
unfrequently  hastened  by  an  intervening  attack  of  bronchitis  or 
of  pneumonia, — a  fact  which  teaches  us  not  to  neglect  examining 
the  lungs  in  cases  of  croup,  so  as  to  be  sure  that  no  disease  is 
there  silently  running  its  course  with  its  symptoms  masked  by 
the  tracheal  malady.  In  this  respect,  auscultation  affords  us 
important  information,  much  more  important  than  any  it  yields  as 
to  the  exact  seat  and  the  extent  of  the  affection  of  the  windpipe. 

Still,  the  application  of  a  stethoscope  to  the  larynx  or  trachea  is 
not  without  value.  It  may  enable  us  to  judge  of  the  position  of 
the  exudation,  for  we  may  occasionally  hear  a  vibrating  sound,  as 
if  a  membrane  were  being  tossed  to  and  fro  by  a  current  of  air. 
In  a  case  that  came  under  my  notice  several  years  ago,  this  sign 
was  perceived  with  great  distinctness  at  the  lower  part  of  the 
trachea,  and  toward  the  commencement  of  the  left  bronchial  tube ; 
and  at  the  autopsy,  at  exactly  this  point  was  found  a  thick  layer 
of  membrane  lying  unattached  in  the  tube. 

Croup  is  a  disease  not  apt  to  be  mistaken.  Yet  we  must  be 
cautious  not  to  attach  too  much  weight  to  any  one  of  the  symp- 
toms ;  we  ought  rather  to  judge  of  the  existence  of  the  disorder 
by  their  grouping.     Thus,  the  ringing  cough  is  in  itself  by  no 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  209 

means  diagnostic,  for  it  may  occur  in  some  chronic  laryngeal 
affections,  and  it  is  met  with  in  children  suffering  from  intestinal 
irritation.  The  stridulous  respiration  is  also  heard,  or  at  all  events 
there  is  a  tolerably  close  copy  of  it,  in  simple  spasm  of  the  glottis, 
and  sometimes  when  foreign  bodies  have  found  their  way  into  the 
larynx.  The  paroxysms  of  apparent  suffocation  happen  equally 
in  oedema  of  the  glottis.  JMot  even  the  symptom  considered  of 
all  the  most  pathognomonic — the  expectoration  of  false  membrane 
— is  strictly  so,  since  this  may  come  from  the  bronchial  tubes  or 
from  the  throat.  But  when  we  take  the  symptoms  collectively, 
— the  ringing  cough,  the  peculiar  respiration,  the  dyspnoea  ag- 
gravated in  paroxysms,  the  changed  voice,  the  fever,  the  expec- 
toration ;  when  we  regard  the  comparatively  short  duration  of 
the  disease, — there  is  but  one  interpretation  of  the  phenomena 
possible,  and  that  is  true  croup. 

It  is,  of  course,  of  the  utmost  consequence  to  distinguish  be- 
tween spasmodic  laryngitis  or  false  Group  and  membranous  croup. 
The  main  difference  consists  in  this:  in  the  former,  the  invasion 
is  usually  more  sudden  ;  we  do  not  find  the  pharyngeal  exudation 
so  often  seen  in  true  croup ;  there  is  little  fever,  or  this  disappears 
with  the  paroxysm;  and  so  do  the  croupal  breathing,  and,  to  a 
great  extent,  the  hoarse  voice  and  loud,  barking  cough.  The 
disorder  lasts  rarely  more  than  two  or  three  days,  the  attack  usually 
occurring  at  night ;  whereas  in  true  croup  the  duration  is  seldom 
less  than  from  four  to  six  days,  and  the  disease  progresses  steadily, 
and  the  voice  and  respiration  show  at  all  times  the  nature  of  the 
affection.  Then  in  the  latter  we  find  expectoration  of  false  mem- 
brane. This  is,  indeed,  the  most  absolute  proof;  yet  the  absence 
of  membrane  in  what  is  coughed  up  or  vomited  is  not  a  positive 
sign  that  the  case  is  not  one  of  membranous  croup.  The  mem- 
brane may  be  retained  in  the  larynx ;  and  we  meet,  indeed,  with 
instances  in  which  it  is  impossible  to  say  whether  the  inflammation 
has  or  has  not  produced  a  plastic  exudation ;  whether,  in  other 
words,  the  case  is  a  severe  one  of  false  croup,  or  one  of  membra- 
nous croup. 

The  disorders  which,  next  to  false  croup,  are  most  likely  to 
be  mistaken  for  the  formidable  malady  under  consideration,  are  : 
acute  laryngitis,  oedema  of  the  glottis,  diphtheria,  and  retro- 
pharyngeal abscesses. 

14 


210  MEDICAL    DIAGNOSIS. 

Acute  laryngitis  is,  like  croup,  a  disease  of  short  duration,  and, 
like  croup,  attended  with  a  changed  voice,  with  a  harsh  cough, 
and  with  dyspnoea.  But  it  attacks  adults,  not  children.  It  pre- 
sents difficulty  in  swallowing,  for  which  the  slight  marks  of  in- 
flammation in  the  fauces  are  insufficient  to  account;  whereas  in 
croup,  in  spite  of  the  pharyngeal  exudation,  there  is  little  or  no 
difficulty  in  swallowing.  A  form  of  laryngitis,  however,  happens 
in  children,  which  is  very  liable  to  be  considered  as  croup;  it  is 
the  secondary  laryngitis  of  the  exanthemata,  especially  of  variola. 
Attention  to  the  history  of  the  case,  and  to  the  circumstance  of 
the  inflammation  having  spread  from  the  throat  downward,  will 
go  a  great  way  toward  forming  a  correct  opinion  of  the  disease. 
Yet  the  diagnosis  is  sometimes  one  of  extreme  difficulty,  and, 
if  the  characteristic  expectoration  of  croup  be  absent,  the  most 
accomplished  physician  may  be  deceived. 

(Edema  of  the  glottis  resembles  croup  in  the  dyspnoea,  the  fits 
of  suifocation  and  of  coughing,  the  altered  voice,  and  the  noisy 
inspiration.  It  resembles  it  further  in  the  fact  that  most  of  the 
symptoms  do  not  disappear  in  the  intervals  between  the  par- 
oxysms. Here  is  certainly  a  strong  likeness.  But  the  cough  has 
not  the  croupal,  brazen  sound  ;  expiration  is  comparatively  un- 
embarrassed; there  is  no  fever,  unless  the  oedema  occur  in  the 
course  of  an  acute  affection;  and,  above  all,  oedema  of  the  glottis 
is  a  disease  of  adults,  and  is  unattended  with  the  peculiar  expec- 
toration. Again,  the  history  of  the  case  often  guards  against  error, 
for  oedema  of  the  glottis  happens  frequently,  perhaps  most  fre- 
quently, in  those  who  have  been  long  laboring  under  ulcerative 
laryngitis.  In  cases  in  which  we  are  able  to  use  the  laryngeal 
mirror,  the  peculiar  oedematous  look  of  the  parts  is  readily 
recognized. 

The  sore-throat  of  diphtheria  may  be  attended  by  the  same 
expectoration  as  croup ;  the  walls  of  the  pharynx,  and  the  fauces, 
too,  are  coated  with  false  membrane.  But  we  know  that  the  wind- 
pipe is  not  the  seat  of  the  complaint  by  the  absence  of  paroxysms 
of  cough  and  of  difficulty  in  breathing,  and  by  the  voice  being 
unchanged  or  somewhat  nasal,  but  not  husky  or  extinct.  And 
there  are  some  other  points  of  difference  which  we  shall  farther 
on  inquire  into;  and  especially  shall  we  examine  into  the  relation 
of  membranous  croup  to  laryngeal  diphtheria. 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  211 

Retropharyngeal  abscesses  share  with  croup  the  dyspnoea,  the 
stridulous  respiration,  and  the  altered  voice.  They  do  not,  how- 
ever, share  with  it  the  expectoration  of  false  membrane  or  the 
peculiar  cough;  and,  further,  in  croup  there  is  not  that  difficulty  in 
swallowing,  or  that  evident  tumefaction  and  stiffness  of  the  neck, 
nor  can  a  tumor  be  recognized  by  the  touch,  as  it  can  be  when 
an  abscess  is  seated  behind  the  walls  of  the  pharynx.  Moreover, 
the  dyspnoea  and  the  voice  present  somewhat  different  charac- 
teristics. In  the  case  of  abscess,  the  former  is  greatly  augmented 
or  paroxysms  of  it  are  brought  on  by  attempts  at  deglutition ;  it 
is  always  preceded  by  dysphagia,  is  increased  by  pressure  against 
the  larynx,  and  frightfully  aggravated  by  the  horizontal  position. 
In  croup,  the  patient  seeks  relief  by  throwing  back  his  head,  and 
although  he  loses  his  voice  and  speaks  in  a  hardly  audible  whisper, 
still  the  words  are  sufficiently  distinct ;  while  an  abscess  gives  a 
nasal  or  guttural  tone  to  the  voice,  which  makes  it  impossible  to 
understand  what  is  being  said. 

Abscess  of  the  larynx  bears  a  strong  resemblance  to  retro- 
pharyngeal abscess,  and  may,  therefore,  like  it,  be  mistaken  for 
croup.  Abscess  of  the  larynx  in  its  acute  and  primary  form  is 
not  a  frequent  disease :  rare  in  adults,  it  is  still  rarer,  as  Parry 
well  points  out,*  in  children.  No  swelling  can  be  detected  in  the 
pharynx  to  account  for  the  pain,  the  cough,  the  difficult  breathing 
and  impeded  swallowing;  but  on  close  observation  it  is  found 
that  the  larynx  projects,  and  that  there  is  induration  at  the  pos- 
terior margin  of  the  thyroid  cartilage.  The  neck  is  not  markedly 
swollen,  as  in  diffuse  inflammation  of  the  cellular  tissue.  With 
the  laryngoscope  we  observe  a  circumscribed  swelling,  red  at  base, 
and  often  yellowish  at  its  apex.  We  do  not  find,  as  we  so  com- 
monly observe  in  croup,  that  both  inspiration  and  expiration  are 
interfered  with;  the  latter,  indeed,  may  be  both  unembarrassed  and 
noiseless. 

Further,  croup  may  be  mistaken  for  tonsillitis,  for  capillary 
bronchitis,  for  hooping-cough,  or  for  the  presence  of  foreign 
bodies  in  the  larynx  or  trachea.  But  to  any  but  the  most  careless 
observer  the  points  of  distinction  are  evident.  In  tonsillitis,  the 
breathing  is  not  at  all  or  but  very  slightly  impaired;  and  a  glance 

*  Philadelphia  Medical  Times,  June,  1873. 


212  MEDICAL    DIAGNOSIS. 

into  the  mouth  is  sufficient  to  reveal  the  real  nature  of  the  mal- 
ady. In  capillary  bronchitis,  there  is  dyspnoea,  as  in  croup;  but 
the  dyspnoea  is  unremitting,  and  associated  with  fine  rales  in  the 
lungs,  and  not  with  a  ringing  cough,  a  harsh  tracheal  breathing, 
a  hoarse  voice.  In  hooping-cough,  paroxysms  of  coughing  and 
of  obstructed  respiration  occur;  but  then  follows  the  distinctive 
hoop;  and  there  is  no  fever,  the  voice  is  not  husky,  and  the  child 
does  not  suffer  between  the  coughing-spells.  Foreign  bodies  in 
the  windpipe  give  rise  to  stridulous  breathing  and  to  cough,  but 
they  do  not  often  mimic  croup  closely  enough  to  deceive;  and  the 
absence  of  the  peculiar  cough  and  of  fever,  and  the  history  of  the 
case,  prevent  error;  so  also  does  attention  to  the  fact  that  the  signs 
vary  as  the  foreign  body  shifts  its  position.  Furthermore,  as  Dr. 
Gross*  in  his  elaborate  work  points  out,  the  embarrassed  breathing 
caused  by  a  foreign  body  is  chiefly  found  in  expiration. 

Chronic  Laryngeal  Affections. 

Of  the  chronic  diseases  of  the  larynx,  chronic  inflammation  of 
the  mucous  membrane  and  the  changes  produced  in  it  by  inflam- 
mation, thickening  and  ulceration,  are  the  most  common. 

Chronic  Laryngitis. — This  affection  has  as  its  main  symp- 
tom an  alteration  of  the  voice;  but  it  is  also  accompanied  by 
cough  and  by  an  uneasy  feeling  in  the  larynx.  The  cough  is  at  first 
dry,  but  when  of  any  standing  is  followed  by  a  yellowish  opaque 
expectoration.  It  either  presents  nothing  peculiar  in  its  tone, 
or  else  is  harsh  and  barking.  The  breathing  is  little,  if  at  all, 
embarrassed,  except  when  the  mucous  textures  are  greatly  thick- 
ened or  ulcerated.  In  that  case  there  is  dyspnoea,  the  respiration 
is  apt  to  be  noisy  and  the  voice  completely  lost,  because  the  vocal 
cords  have  also  suffered.  There  is,  moreover,  considerable  pain 
on  pressure ;  the  sputum  is  muco-purulent,  or  else  purulent  and 
streaked  with  blood  ;  and  sometimes,  if  the  cartilages  also  be  in- 
volved, fragments  of  them  are  expectorated,  and  by  the  touch  we 
recognize  the  changed  state  of  the  tube. 

The  symptoms  of  chronic  laryngitis  are  purely  local.  It  is 
only  when  there  is  considerable  ulceration  or  a  progressive  altera- 

*  On  Foreign  Bodies  in  the  Air-Passages. 


DISEASES    OF    THE    UPPER    AIK-PASSAGES.  213 

tion  of  structure  in  the  affected  part  that  the  general  health  gives 
way.  Yet  chronic  laryngitis  is  frequently  found  to  be  connected 
with  a  broken  constitution,  because  the  inflammation  of  the  larynx, 
both  in  its  simple  and  in  its  ulcerated  form,  is  often  combined 
with  a  tubercular  cachexia,  or  with  syphilis.  In  every  patient, 
therefore,  who  places  himself  under  our  care,  suffering  from 
chronic  laryngitis,  we  must  endeavor  to  ascertain,  by  careful 
inquiry,  whether  either  of  these  morbid  conditions  be  present. 
Many  a  time  what  has  been  considered  as  pure  chronic  laryn- 
gitis turns  out,  on  thorough  examination,  to  be  laryngitis  linked 
to  a  serious  pulmonary  difficulty ;  or  in  other  instances  we  detect 
ulcers  in  the  pharynx  associated  with  those  in  the  larynx,  and 
are  enabled  to  trace  clearly  the  ravages  of  constitutional  syphilis. 

Chronic  laryngitis  is  liable  to  be  mistaken  for  an  aneurism  of 
the  aorta,  or,  more  strictly  speaking,  an  aneurism  of  the  aorta  is 
liable  to  be  regarded  and  treated  as  a  case  of  chronic  laryngitis. 
The  distinction,  as  will  hereafter  be  shown,  is  mainly  made  by 
attention  to  the  physical  signs. 

Cases  of  functional  or  nervous  aphonia,  too,  are  sometimes  con- 
founded with  chronic  laryngitis ;  and  it  is  by  no  means  always 
easy  to  avoid  this  error.  The  loss  of  voice  may  be  either  partial 
or  complete.  It  not  unfrequently  comes  on  without  any  previous 
warning;  and  this  fact  aids  us  greatly  in  diagnosis.  So  does  the 
absence  of  cough,  of  expectoration,  of  local  pain,  and  of  all  diffi- 
culty in  breathing;  for  none  of  these  symptoms  are  commonly 
observed  in  aphonia  which  is  solely  nervous.  One  of  the  causes 
of  the  disorder  is  overstimulation  of  the  vocal  nerves,  by  straining 
the  voice  in  singing  or  in  speaking.  We  also  meet  with  it  as 
occasioned  by  narcotics  or  by  lead  poisoning,  and  perhaps  most 
frequently  as  a  reflex  manifestation,  due  to  irritation  of  the  intes- 
tines by  worms,  or  to  a  disorder  of  the  uterine  system.  In  these 
instances  of  nervous  aphonia  the  voice  suddenly  disappears  and 
as  suddenly  reappears,  a  phenomenon  not  unusual  in  the  aphonia 
of  hysteria ;  and  we  may  have  from  impaired  but  not  wholly  lost 
power  the  voice  absent  only  for  some  hours  daily.  It  is  evident 
that  in  all  cases  of  nervous  aphonia  the  laryngoscope  will  assist 
us  greatly  in  diagnosis,  as  it  will  show  us  the  true  condition  of 
the  parts,  as  regards  both  their  structure  and  their  mobility.  It 
also  aids  us  in  distinguishing  these  laryngeal  disorders  from  cases 


214  MEDICAL    DIAGNOSIS. 

of  aphonia  due  to  want  of  strength  in  breathing, — to  want  of 
power  in  expiration. 

Enlarged  bronchial  and  cervical  glands,  and  an  aneurism  which 
paralyzes  the  vagus  and  the  recurrent  nerve,  also  produce  hoarse- 
ness, and  ultimately  complete  loss  of  voice.  Under  such  circum- 
stances, the  trachea  is  insensible  to  pressure ;  there  is  a  short  cough, 
attended  often  with  loud  tracheal  rales ;  and  we  observe  attacks 
of  dyspnoea,  with  a  noisy,  hissing  respiration.  The  practical  les- 
son which  all  such  cases  teach,  is  to  remember  that  the  symptom 
considered  most  characteristic  of  chronic  laryngeal  inflammation 
— the  altered  voice — may  occur  when  no  laryngitis  exists. 

Now,  in  the  nervous  forms  of  aphonia  just  alluded  to,  with 
the  exception  of  those  caused  by  pressure,  the  loss  of  voice  is  due 
to  deficient  power,  and  the  cords  move  sluggishly  or  not  at  all. 
When  the  disorder  reaches  a  high  degree,  we  perceive,  on  looking 
into  the  laryngeal  mirror,  that  the  vocal  cords  do  not  approximate 
as  the  patient  attempts  to  say  a  or  o.  But,  besides  these  cases, 
owing  to  general  want  of  force,  we  find  cases  of  absolute  paralysis 
of  individual  muscles,  as  of  one  adductor  of  a  cord ;  or  of  one 
or  both  posterior  crico-ary tenoids,  or  abductors ;  or  of  the  crico- 
thyroids, or  tensors.  In  some  of  these  there  is  considerable  dysp- 
noea, with  noisy  breathing;  in  all  the  laryngoscope  aiFords  the 
only  means  of  diagnosis.*  In  paralysis  of  the  tensors  of  the 
vocal  cords,  the  crico-thyroid  muscles,  there  is  inability  to  use  with 
any  freedom  the  higher  notes;  the  voice  is  rough,  and  viewed 
with  the  mirror  we  find  in  phonation  a  want  of  longitudinal  ten- 
sion. It  most  frequently  results  from  overstraining  the  voice,  and 
is  apt  to  be  bilateral.  Palsy  of  the  thyro-epiglottic  muscles  has 
its  common  origin  in  diphtheria.  The  epiglottis  stands  erect,  and 
does  not  move  during  attempts  at  deglutition.  In  palsy  of  the 
relaxors  of  the  vocal  cords,  the  thyro-arytenoid  muscles,  the  deep 
tones  are  nearly  gone.  It  is  often  unilateral,  and  comes  mostly 
from  overexertion  of  the  voice  during  catarrhal  laryngitis.  Viewed 
in  the  laryngeal  mirror,  the  edges  of  the  cords  do  not  approach  in 
the  median  line,  and  the  edges  seem  excavated.     In  paralysis  of 


*  See  Morell  Mackenzie,  London  Hospital  Keports,  vol.  iv.  ;  also,  Oliver, 
American  Journal  of  the  Medical  Sciences,  April,  1870 ;  and  Ziemssen,  in 
Ziemssen's  Cyclopaedia. 


DISEASES    OF    THE    UPPER    AIK-PASSAGES.  215 

the  posterior  crico-arytenoid  muscles,  we  see  in  the  mirror  the 
glottis  merely  as  a  narrow  slit,  becoming  still  narrower  during 
inspiration.  There  is  no  disturbance  of  voice,  and  scarcely  any 
sign  of  laryngeal  catarrh,  but  there  is  most  marked  and  noisy 
laryngeal  dyspnoea. 

Chronic  laryngitis,  or  rather  its  chief  symptom,  loss  of  voice,  is 
at  times  feigned;  and  the  deception  may  be  kept  up  for  an  indefi- 
nite period.  Yet  we  possess,  in  the  use  of  anesthetics,  the  means 
of  detecting  the  fraud  at  any  moment.  Just  before  the  impostor 
falls  into  the  deep  sleep  produced  by  ether,  or  as  he  is  recovering 
from  the  insensibility  it  occasions,  his  will  no  longer  controls  his 
voice,  and  he  speaks  in  his  natural  tone,  or  even  screams  violently. 

Now,  under  the  term  chronic  laryngitis,  which  formerly  for 
want  of  more  precise  knowledge  was  made  to  embrace  most  kinds 
of  chronic  diseases  of  the  larynx,  many  different  morbid  processes 
are  embraced,  the  exact  nature  and  seat  of  which  we  may  discrim- 
inate by  the  laryngoscope.  Thus,  the  disorder  may  be  wholly, 
or  nearly  wholly,  confined  to  the  epiglottis.  We  may  find  this 
structure  highly  congested  and  enlarged ;  we  may  be  able  to  note 
that  it  is  pendent,  almost  completely  covering  the  glottis ;  and  it 
is  frequently  the  seat  of  ulceration.  The  attending  symptoms  in 
any  case  are  those  regarded  as  characteristic  of  a  greater  or  less 
degree  of  laryngeal  inflammation.  In  instances  of  ulceration, 
there  is  soreness  with  pain  in  swallowing,  hoarseness  and  irritative 
cough,  followed  at  times  by  blood-streaked  expectoration.  The 
ulceration  may  terminate  in  total  destruction  of  the  epiglottis. 

When  the  vocal  cords  are  affected,  we  recognize  in  the  laryngeal 
mirror  either  their  reddening  in  part  or  entirely,  or  their  indura- 
tion and  thickening,  or  we  observe  cedematous  swelling  in  and 
around  them,  or  their  ulceration;  and  we  can  usually  detect 
during  breathing  and  phonation  their  impaired  action.  Xow,  all 
these  conditions  are  generally  combined  with  marked  aphonia; 
the  voice,  indeed,  may  be  reduced  to  the  merest  whisper.  In 
making  our  diagnosis  we  must  always  be  careful  to  find  out  if  the 
laryngeal  phenomena  be  not  secondary,  forming  part  of  a  general 
morbid  state,  such  as  dropsy,  tuberculosis,  syphilis,  or  changes  in 
the  blood. 

Diseases  of  the  cartilages  and  of  the  jjerichondrium  are  still  more 
frequently  occasioned  by  the  conditions  alluded  to;  tuberculosis, 


216  MEDICAL   DIAGNOSIS. 

syphilis,  and  low  forms  of  fever  are,  at  all  events,  the  states  with 
which  they  are  commonly  combined.  The  affection  often  begins 
in  the  submucous  tissue,  and  the  ulceration  spreads  until  the  car- 
tilaginous parts  of  the  larynx  are  involved.  The  arytenoid  car- 
tilages are  generally  those  first  attacked;  and  portions  of  these 
cartilages  may  be  thrown  off  and  expelled.  At  times  pus  is 
formed  which  gives  rise  to  swellings  that  can  be  recognized  by  the 
aid  of  the  laryngeal  mirror;  sometimes  a  displacement  of  the  car- 
tilages takes  place,  before  any  portion  of  them  is  completely  sepa- 
rated, and  the  most  distressing  and  dangerous  attacks  of  suffoca- 
tion result ;  or  the  perichondritis  may  lead  to  the  development  of 
bone-substance  and  a  constriction  of  the  tube.  In  some  instances 
the  purulent  collection  presses  on  a  vocal  cord,  which,  when  the 
laryngoscope  is  used,  may,  as  Tuerck*  has  recorded,  be  seen  to  be 
immovable.  This  instrument  reveals  very  often  the  ravages  the 
disease  has  committed;  and  we  are  thus  generally  enabled  to  form 
an  opinion  as  to  how  far  the  destruction  or  the  laryngeal  phthisis 
has  progressed,  and  which  of  the  soft  parts  as  well  as  of  the  car- 
tilages are  involved.  The  symptoms  attending  this  terrible 
complaint  are  difficulty  in  breathing  and  in  swallowing,  local 
pain  and  soreness,  a  greatly  altered  or  a  lost  voice,  and  a  dis- 
tressing, harsh  cough,  which  is  followed  at  times  by  a  purulent 
expectoration. 

As  the  result  of  disease  of  the  cartilage  and  of  the  perichon- 
drium, especially  as  the  result  of  the  process  of  cicatrization,  we 
may  have  stricture  of  the  larynx  and  trachea;  for  this  is,  in  truth, 
the  most  common  origin  of  laryngeal  stenosis.  The  inspiration 
is  prolonged  and  noisy;  the  voice  is  generally,  although  not  of 
necessity,  affected.  There  is  dyspnoea,  and  with  the  laryngoscope 
we  can  generally  see  how  greatly  the  calibre  of  the  tube  has  been 
encroached  upon. 

Ulcers  in  the  posterior  walls  of  the  larynx  give  rise,  as  a  rule, 
to  distressing  cough.  Respecting  tumors  of  the  larynx,  cancerous 
or  otherwise,  and  polypoid  growths  in  its  interior,  we  do  not 
know  as  yet  sufficient  to  distinguish  them  with  any  certainty,  by 
their  symptoms  alone,  from  chronic  laryngitis.  Their  most  trust- 
worthy  signs,  irrespective  of  the  cough,  altered   voice,  and  the 

*  Clinical  Besearches,  transl.,  London,  1862. 


DISEASES    OF    THE    UPPER    AIR-PASSAGES.  217 

other  manifestations  of  chronic  laryngeal  inflammation,  are  a 
steadily  increasing  difficulty  in  breathing  and  attacks  of  suffoca- 
tion, for  which  nothing  in  the  lungs,  or  heart,  or  great  vessels 
accounts.  The  detection,  at  the  seat  of  the  larynx,  of  a  growing 
tumor,  accompanied  by  a  severe  cough,  by  a  sanious  sputum,  and 
by  emaciation,  would,  in  addition  to  the  symptoms  just  enumer- 
ated, warrant  the  diagnosis  of  cancer,  whether  or  not  much  pain 
were  present.  Polypi  in  the  larynx  may  sometimes  be  seen  by 
depressing  and  dragging  forward  the  tongue  until  the  epiglottis 
is  brought  into  view.  At  least  they  have  been  thus  discovered, 
and  even  successfully  operated  upon.*  But  as  regards  polypi,  or, 
indeed,  any  form  of  morbid  growth,  we  possess  in  the  laryngo- 
scope the  most  certain,  usually  the  only  certain,  means  of  detecting 
them,  and  even  of  aiding  us  in  removing  them,  as  is  now  being 
constantly  done.  These  laryngeal  growths  vary  much  in  size  and 
in  color ;  they  are  often  seated  at  the  anterior  free  edges  of  the 
true  cords,  or  still  more  generally  just  above  or  just  below  their 
origin.  I  have  seen  numerous  instances  of  the  kind  ;  and  they 
are,  as  a  rule,  very  readily  discerned.  Sometimes  they  may  exist 
for  years,  merely  producing  changes  in  the  voice  and  some  cough, 
but  no  very  great  distress  ;  or  they  may  lead  to  fits  of  strangula- 
tion and  to  sudden  death.  It  is  impossible  to  be  sure  of  their 
nature  without  repeatedly  examining  portions  of  them.  Papil- 
lomas are  usually  cauliflower-like  or  in  bunches;  they  occupy 
most  frequently  the  vocal  cords,  while  sarcomas  are  oftenest  found 
at  the  anterior  portion  of  the  larynx.  Cysts  of  the  vocal  cords 
are  much  rarer  than  other  forms  of  growths ;  they  sometimes 
rupture  spontaneously,  and  the  hoarse  voice  quickly  clears.f 

Before  concluding  these  remarks  on  diseases  of  the  larynx,  it 

*  Horace  Green,  Polypi  of  the  Larynx.  Also,  Ehrmann,  Histoire  des 
Polypes  du  Larynx,  Strasbourg,  1850 ;  Buck,  Transact,  of  Amer.  Med.  As- 
sociation,'vol.  vi.  A  number  of  cases  in  which  the  laryngoscope  showed  its 
great  usefulness  are  given  by  Elsberg,  ib.,  1865,  and  Archives  of  Laryngology. 
No.  1,  1880;  in  Cohen's  Treatise  on  Diseases  of  the  Throat,  second  edition. 
New  York,  1879;  in  Morell  Mackenzie's  monograph,  Essay  on  Growths  in 
the  Larynx,  London,  1871  ;  and  in  Von  Brun's  publications,  Polypen  des 
Kehlkopfes,  Tubingen,  1868,  Laryngotomie  zur  Entfernung  endolaryngealer 
Neubildungen,  Berlin,  1878,  etc. 

j  Heinze,  Archives  of  Laryngology.  New  York,  1880. 


218  MEDICAL    DIAGNOSIS. 

may  be  thought  necessary  to  point  out  the  differences  between 
them  and  diseases  of  the  trachea.  But  affections  of  the  trachea 
need  not  be  separately  considered.  Lying  between  the  larynx 
and  the  bronchi,  the  trachea  commonly  shares  in  their  disorders. 
Thus,  we  have  seen  croup  to  be  a  malady  in  which  both  larynx 
and  trachea  are  involved.  Slight  inflammation  of  the  trachea 
occurs  constantly  in  slight  attacks  of  laryngitis  or  of  bronchitis. 
Ulcers  in  the  trachea  may  exist  without  ulceration  of  the  larynx ; 
but  then  they  usually  escape  detection.  Sometimes,  however,  they 
reveal  themselves  by  a  constant  pain  at  the  lower  portion  of  the 
neck  and  the  upper  part  of  the  sternum,  joined  to  all  the  symptoms 
of  ulceration  of  the  larynx  except  the  impaired  voice.  Morbid 
growths,  too,  occur  in  the  trachea,  as  they  do  in  the  larynx,  and 
the  tube  may  be  altered  in  form  and  in  structure.  We  can  make 
use  of  the  laryngoscope  to  assist  us  in  the  diagnosis  of  any  of  the 
forms  of  tracheal  disease  referred  to.  Yet  the  instrument  is  not 
always  available ;  for  it  is  only  under  very  favorable  circumstances 
that  the  entire  extent  of  the  trachea  can  be  seen. 

In  narroiving  of  the  trachea  the  bronchial  tubes  are  also  at  the 
same  time  often  narrowed.  The  stenosis  may  be  caused  by  ex- 
ternal compression,  as  from  a  goitre,  from  an  aneurism,  or  from  a 
mediastinal  tumor;  or  the  constriction  may  be  due  to  some  cause, 
such  as  new  formations,  in  the  walls  of  the  tubes.  The  chief 
symptoms  are  the  same  in  either  case;  and  they  are,  long-drawn- 
out  respiratory  acts,  noisy  breathing,  especially  in  paroxysms, 
dyspnoea,  particularly  marked  in  inspiration,  epigastric  retraction, 
feebleness  or  absence  of  vesicular  murmur,  with  clear  pulmonary 
resonance,  loud  wheezing  heard  with  the  stethoscope  at  or  near 
the  place  of  constriction,  and  voice  slightly,  if  at  all,  impaired. 
This,  the  normal  appearance  of  the  larynx  as  shown  by  the  laryn- 
goscope, and  the  almost  imperceptible  motion  of  the  windpipe 
during  breathing,*  are  of  great  value  in  distinguishing  a  tracheal 
from  a  laryngeal  stenosis.  A  bronchial  stenosis  is  chiefly  dis- 
criminated by  the  signs  of  the  constriction  being  one-sided,  and 
attended  with  marked  thrill  of  the  thoracic  wall  of  the  affected 
side,  and  with  loud  sounds  issuing  from  it,  loud  enough  to  be 
heard  at  a  distance. 

*  Gerhardt ;  also  Kiegel,  in  Ziemssen's  Cyclopaedia. 


CHAPTER   IV 


DISEASES    OF    THE    CHEST. 


An  examination  of  the  diseases  of  the  chest  must  be  prefaced 
by  a  description  of  the  methods  of  investigation  which  have  given 
to  their  diagnosis  such  certainty.  The  same  methods  may  be  ap- 
plied in  the  study  of  the  maladies  of  other  parts  of  the  body,  but 
they  are  of  special  service  in  the  recognition  of  thoracic  disorders, 
and  will  be  here,  therefore,  most  appropriately  considered. 

The  discrimination  of  disease  by  the  eye,  the  ear,  the  touch,  in 
fact  by  the  direct  aid  of  the  senses,  is  called  physical  diagnosis ; 
the  signs  thus  ascertained  are  connected  with  perceptible  altera- 
tions in  the  material  properties  or  physical  nature  of  structures, — 
such  as  alterations  in  their  form,  their  density,  or  their  sounds, — 
and  are  known  as  physical  signs. 

Physical  signs  are,  then,  the  exponents  of  physical  conditions, 
and  of  nothing  more.  But  as  the  same  physical  conditions  may 
occur  in  various  diseases,  so  may  the  same  physical  signs  occur  in 
various  diseases.  An  isolated  sign  is,  therefore,  not  diagnostic  of 
any  particular  malady.  It  reveals  usually  an  anatomical  change ; 
but  it  does  not  determine  the  disorder  occasioning  this  change. 
The  tendency  to  ascribe  to  each  thoracic  affection,  and  even  to 
each  stage  of  an  affection,  a  pathognomonic  sign,  has  greatly  re- 
tarded the  usefulness  of  physical  exploration.  By  presenting  a 
never-ending  list  of  specific  signs,  it  has  frightened  many  from 
attempting  to  become  acquainted  with  the  most  serviceable  of  all 
the  means  of  diagnosis,  and  many  more,  by  the  unnecessary  compli- 
cations introduced,  have  been  disheartened  at  the  very  threshold 
of  their  studies.  The  subject  may  be  much  simplified  by  laying 
less  stress  on  individual  signs,  and  by  grouping  them  together 
according  as  their  association  becomes  distinctive  of  certain  well- 
marked  physical  states.  Morbid  anatomy  then  steps  in  with  its 
teachings,  and  tells  us  in  what  diseases  these  states  are  commonly 

219 


220  MEDICAL    DIAGNOSIS. 

found.     It  is  in  conformity  with  these  views  that  I  shall  attempt, 
in  the  following  pages,  to  delineate  the  signs  of  thoracic  affections. 

But  physical  signs  cannot  be  acquired  from  books ;  they  must 
be  learned  at  the  bedside.  Their  value  can  be  ascertained  by 
reading;  yet  to  distinguish  them  with  readiness  requires  constant 
cultivation  of  the  eye,  of  the  ear,  and  of  the  sense  of  touch.  And 
it  is  of  great  importance  to  have  clear  ideas  regarding  the  structure 
of  the  parts  to  be  investigated,  and  of  their  action  in  health.  It 
must,  for  instance,  be  borne  in  mind  that  the  lung  is  covered  by  a 
serous  investment;  and  that  it  consists  of  tubes  more  or  less  rigid, 
the  bronchial  tubes,  with  their  numerous  ramifications,  and  of  their 
termination  in  an  elastic  parenchyma,  the  air-vesicles,  or  the  pul- 
monary tissue  proper.  It  must  further  be  borne  in  mind  that  the 
organ  is  separated  into  lobes,  and  contains  air  which  is  constantly 
shifting,  and  that  locked  up  with  the  lungs  in  the  same  cavity  i- 
the  main  organ  of  circulation. 

For  the  sake  of  convenience,  the  surface  of  the  chest  has  been 
mapped  out  into  regions.  Various  arrangements  of  these  have 
been  made  by  different  authors.  The  simplest  division  of  the 
chest  is  into  anterior,  posterior,  and  lateral  surfaces.  The  regions 
into  which  the  anterior  surface  may,  for  practical  uses,  be  sub- 
divided, are :  an  upper  region,  extending  from  just  above  the 
clavicle  to  the  fourth  rib,  and  a  lower  region,  from  the  fourth  rib 
downward.  Posteriorly,  also,  there  are  an  upper  and  a  lower 
part  of  the  chest  to  be  specially  examined.  It  is  hardly  necessary 
to  say  that  all  these  regions  are  double, — the  same  on  each  side  of 
the  chest.  Many  more  divisions  are  usually  made;  but  they  are 
perplexing  to  the  student,  and  of  doubtful  value.  The  artificial 
boundaries  generally  laid  down  are,  indeed,  too  minute  and  yet 
not  minute  enough  ;  they  are  too  minute  for  ordinary  purposes, 
not  minute  enough  when  it  is  desirable  to  localize  a  physical  sign. 
Whenever  this  is  requisite,  instead  of  resorting  to  the  names  of 
the  regions  usually  employed,  I  think  it  preferable  to  designate 
the  seat  of  the  sign  with  reference  to  some  fixed  anatomical  point. 
This  may  be  done  for  the  anterior  part  of  the  chest  by  indicating 
the  distance  above  or  below  the  clavicle,  or  near  what  part  of  the 
sternum,  or  at  which  rib,  or  spreading  over  how  many  intercostal 
spaces,  the  sign  in  question  is  perceived.  At  the  posterior  part  of 
the  chest,  the  spinous  ridge  of  the  scapula,  its  lower  angle,  and 


DISEASES    OF    THE    LUNGS.  221 

the  spinal  column,  serve  as  landmarks.  For  most  clinical  pur- 
poses, it  is  only  needed  to  study  the  region  above  the  spinous 
process  of  the  scapula,  as  separate  from  the  space  below.  But 
in  some  instances  it  may  be  necessary  to  notice  the  region  between 
the  scapulae  (inter-scapular)  or  that  extending  from  the  lower 
angle  of  the  bone  to  the  limits  of  the  chest  (infra-scapular). 

Let  us  now  examine  the  different  methods  of  physical  diagnosis, 
and  particularly  in  their  relation  to  pulmonary  diseases. 


SECTION  I. 

DISEASES   OF  THE   LUNGS. 

The  different  Methods  of  Physical  Diagnosis,  and  the 
Physical  Signs  of  Pulmonary  Diseases. 

INSPECTION. 

If  the  chest  be  examined  with  the  eye,  we  obtain  an  idea  of 
its  form,  size,  and  movements.  In  health  this  inspection  shows 
us  that  the  two  sides  of  the  chest  are,  to  a  great  extent,  sym- 
metrical in  form,  as  well  as  in  size  and  in  movement.  Both  sides 
rise  equally  during  inspiration  and  sink  equally  during  expiration. 
On  both  sides  the  motion  of  inspiration  is  longer  than  that  of 
expiration,  and  the  pause  between  them  extremely  slight. 

This  respiratory  movement  is  visible  over  the  whole  thorax.  In 
males  it  is  most  distinct  at  the  lower  portions  of  the  chest;  in 
females  it  is  most  discernible  at  the  upper.  This  difference  in 
the  two  sexes  becomes  the  more  manifest,  the  more  hurried  the 
breathing.  In  healthy  adults  the  lungs  expand  with  regularity 
from  sixteen  to  twenty  times  in  a  minute.  In  certain  pulmonary 
affections,  especially  in  pneumonia,  the  number  of  respirations 
often  exceeds  fifty  in  a  minute.  But  hurried  breathing  and 
changed  movements  of  the  thorax  occur  independently  of  diseases 
of  the  lung.  The  heaving  of  the  chest  in  a  hysterical  paroxysm 
is  a  sight  familiar  to  every  practitioner.  Where  the  diaphragm 
does  not  descend,  as  in  consequence  of  peritonitis  or  of  abdominal 


222  MEDICAL    DIAGNOSIS. 

dropsy  or  of  tumors,  the  breathing  is  much  more  rapid,  and  is 
perceptible  at  the  upper  parts  of  the  chest.  Again,  the  thoracic 
movements  may  be  distinct  on  one  side  and  hardly  noticeable  on 
the  other,  as  in  pleurisy  or  in  pneumothorax.  Lastly,  as  happens 
in  some  cerebral  lesions,  the  motions  of  the  chest  may  be  very 
slow  and  labored,  or  irregular,  or  they  may  have  apparently 
ceased,  and  the  breathing  be  altogether  abdominal. 

The  form  of  the  chest  is  sometimes  strikingly  altered  by  dis- 
ease. Congenital  malformations,  imperfect  development,  and 
curvatures  of  the  spine  modify  it;  so  do  intra-thoracic  affections. 
Frequently  the  chest  presents  a  retracted  or  an  expanded  look. 
Retraction  denotes  diminished  size  of  the  lung,  and,  if  one-sided, 
is  usually  indicative  either  of  chronic  changes  in  the  lung-tissue, 
as  in  chronic  pneumonia  or  in  the  forms  of  phthisis,  or  of  false 
membranes  which  bind  down  the  lung;  or  it  is  found  in  a  very 
marked  manner  in  empyema  with  external  opening.  Expansion 
of  the  chest  is  met  with  in  emphysema,  in  pneumothorax,  and  in 
pleuritic  effusion.  A  local  or  partial  expansion,  or  bulging,  may 
be  encountered  in  the  latter  disease,  or  it  may  depend  on  thoracic 
tumors,  on  pericardial  effusions,  or  on  hypertrophy  of  the  heart. 

The  size  of  the  chest  can  be  only  approximatively  judged  of 
by  the  eye.  Where  accuracy  is  necessary,  measurements  must  be 
resbrted  to. 

MENSURATION. 

To  measure  the  circumference  of  the  chest  or  of  the  abdomen, 
or  to  ascertain  the  distance  from  one  portion  of  the  surface  to  the 
other,  a  graduated  tape  is  all  that  is  required.  To  attain  the 
former  object,  the  spinous  process  of  a  vertebra  is  chosen  as  a 
fixed  point,  and  the  tape  is  thence  passed  round  the  body  to  the 
median  line,  first  on  one  side,  then  on  the  other,  taking  care  that 
it  be  applied  evenly  to  the  skin,  and  that  the  level  of  the  measure- 
ment be  the  same  on  both  sides.  This  level,  if  the  examination 
be  recorded,  should  always  be  noted,  that  we  may  have  a  uniform 
standard  of  comparison.  And  for  the  same  reason  it  is  best  to 
adopt  the  plan  of  making  our  measurements,  as  nearly  as  pos- 
sible, on  the  same  line:  for  example,  in  determining  the  circular 
width  of  the  thorax,  we  can,  as  a  rule,  select  a  line  immediately 
above  the  nipple,  or  draw  the  tape  around  the  chest  toward  the 


DISEASES    OF    THE    LUNGS. 


223 


Fig.  11. 


sixth  costo-sternal  joint,  and,  therefore,  on  the  level  of  the  sixth 
rib  near  its  attachment  to  the  cartilage.  We  measure  thus  the 
width  of  the  chest ;  if  we  wish  to  obtain  the  longitudinal  diameter, 
the  line  from  the  clavicle  to  the  base  of  the  chest  is  taken.  Where 
the  chest  is  deformed,  Woillez's  cyrtometer  may  be  used  in  place 
of  the  tape. 

In  estimating  the  size  of  the  chest  in  disease,  it  must  be  borne 
in  mind  that  even  in  health  its  two  sides  vary  widely.  The  half- 
circle  on  the  right  side  is,  in  right- 
handed  persons,  at  least  half  an 
inch  larger  than  the  half-circle 
on  the  left.  But  the  measure- 
ments, to  be  trusted,  must  be 
performed  while  the  patient  is 
holding  his  breath  in  expiration. 
In  inspiration  the  girth  of  the 
chest  is  increased  fully  three 
inches.  In  well-developed  men 
it  measures  at  the  upper  part 
about  thirty-three  to  thirty-four 
inches  during  expiration. 

If  it  be  desirable  to  ascertain 
in  how  far  the    respiratory  acts 
modify  the    dimensions    of    the 
chest  or  of  the  abdomen,  this  may  be  readily  effected  by  the  in- 
genious "  chest-measurer"  of  Sibson,  or  by  the  "  stethometer"  of 


The  stethorueter  of  Quain.  The  box  is 
placed  on  the  sternum,  and  the  string  car- 
ried around  the  chest.  One  revolution  of  the 
index,  which  is  moved  by  a  rack  attached  to 
the  string,  indicates  an  inch  of  motion  in  the 
chest. 


Fig.  12. 


The  stetho-goniometer  of  Scott  Alison. 


Quain  or  of  Carroll,*  all  of  which  instruments  register  accurately 
the  movements  of  breathing ;   or  the  respiratory  curves  can  be 


*  New  York  Medical  Journal,  1868. 


224 


MEDICAL    DIAGNOSIS. 


traced  and  studied  by  the  atmograph  of  Burdon  Sanderson,  or  by 
pIG  13  the  anapnograph,  an  in- 

strument made  use  of  by 
Bergeon  and  Kastus,  and 
similar  to  the  sphygmo- 
graph,*  or  by  Riegel's 
double  stethograph. 

The  transverse  diam- 
eter—  the  breadth  —  of 
the  chest  may  be  deter- 
mined by  means  of  a 
pair  of  callipers,  ar- 
ranged specially  for  the 
purpose ;  and  the  curves 
or  flatness  of  the  sur- 
face may  be  ascertained, 
should  it  be  necessary, 
by  Alison's  stetho-goni- 
ometer  (Fig.  12);  but  it 
is  rarely  necessary.  In 
truth,  these  minute  meas- 
urements, however  inter- 
esting to  the  physiolo- 
gist, have,  as  yet,  not 
been  made  available  to 
the  physician.  Inspec- 
tion teaches  us  the  same 
as  mensuration.  What 
it  teaches  with  less  pre- 
cision can  be  learned  for 
purposes  of  diagnosis 
with  a  graduated  tape. 

Mensuration  may  be 
employed  not  only  to 
judge  of  the  size  of  the 
chest  and  of  its  move- 
ments, but  also  to  ascer- 


*  Gazette  Hebdomadaire,  Ser.  2,  v.,  1868. 


DISEASES    OE    THE    LUNGS.  225 

tain  the  amount  of  air  which  is  received  into  the  lungs.  The 
instrument  used  for  this  object  is  the  spirometer,  an  invention  of 
Dr.  John  Hutchinson  (Fig.  13) ;  and  since  his  time  numerous 
modifications  of  the  instrument  have  been  made:  for  instance,  the 
ordinary  dry  and  the  wet  gas-meter  have  been  adapted  to  the  pur- 
poses of  spirometry,  and  an  instrument  small  enough  to  be  carried 
in  the  pocket  has  been  suggested.  The  results  the  spirometer  has 
yielded  are  of  great  value  in  a  physiological  point  of  view ;  in  a 
clinical,  there  are  too  many  sources  of  fallacy  and  too  many  draw- 
backs to  render  them  of  much  importance ;  and  not  the  least  of 
these  drawbacks  is,  that  it  takes  considerable  practice  to  learn  how 
to  blow.  The  spirometer  may  indicate  that  a  large  quantity  of  air 
enters  the  lungs,  and  thus  become  a  rough  test  of  their  normal 
condition.  But  when  less  air  passes  into  the  organ  than  the  spiro- 
metric  standard  requires,  this  leads  in  itself  to  no  conclusions  ; 
certainly  not  to  any  concerning  the  disease  which  occasions  the 
diminished  vital  capacity.  In  estimating  results  arrived  at  by 
the  spirometer,  it  must  be  remembered  that  sex,  weight,  age,  and 
height  have  to  be  taken  into  account.  To  the  latter  Hutchinson 
assigns  much  importance,  since  he  enunciates  the  law  that  for  every 
inch  above  five  feet,  eight  cubic  inches  are  to  be  added  to  the 
healthy  standard.  For  the  height  of  five  feet,  the  breathing 
volume  is  one  hundred  and  seventy-four  cubic  inches.  But  these 
calculations  are  not  exact;  they  only  approximate  the  truth. 
Moreover,  the  vital  capacity  may  be  increased  by  practice,  with 
the  spirometer  or  by  the  use  of  pneumatic  instruments  designed 
to  breathe  in  compressed  air  or  to  breathe  out  into  rarefied  air. 

To  determine  both  the  expiratory  and  the  inspiratory  power, 
the  hsemadynamometer  (Fig.  14)  may  be  employed.  Dr.  Ham- 
mond* lays  great  stress  on  the  indications  furnished  by  testing 
the  inspiratory  power  as  regards  the  health  of  the  individual, 
and  recommends  the  use  of  the  instrument  in  the  examination  of 
recruits.  According  to  his  observations,  healthy  men  of  five  feet 
eight  inches  possess  the  greatest  amount  of  inspiratory  power. 
They  raise  the  column  of  mercury  about  two  inches  by  inspira- 
tion, and  about  three  inches  by  expiration. 

Waldenburg  measures  the  force  in  respiration  by  a  special  appa- 

*  Treatise  on  Hygiene,  Philadelphia,  1863. 
15 


226 


MEDICAL    DIAGNOSIS. 


ratus,  and  has  introduced  pneumatometry  as  a  means  of  diagnosis. 
The  power  exerted  in  expiration  is  greater  than  in  inspiration.    In 


Fig.  14. 


Hon  is  performed,  reverse  moven ent  sri the me    urv  o  rr„°r  ,8»ttached-    When  the  act  of  inspira- 
mnscles  of  the  chest,  and  not  tho* 'of the .month  and  cheeks.  """^  be  tak6D  t0  6Xert  °n,y  the 


some  affections  the  expiratory  pressure  is  largely  diminished, 


as  in 


DISEASES    OF    THE    LTJXGS.  227 

emphysema  and  asthma,  while  in  the  forms  of  phthisis  the  force 
of  inspiration  is  much  lessened. 

PALPATIO^. 

Palpation,  or  the  application  of  the  hand,  confirms  the  results 
obtained  by  inspection  and  mensuration  as  to  size,  form,  and 
movements.  It  may,  in  addition,  be  employed  to  determine  spots 
of  soreness,  the  density  and  condition  of  tumors,  the  state  of  the 
thoracic  walls,  the  frequency  of  the  breathing,  and  the  action  of 
the  heart.  The  hand  may  further  be  of  service  as  a  means  of  dis- 
tinguishing vibrations  produced  by  rhonchi,  rhonchal  fremitus,  or 
by  the  voice,  vocal  fremitus ;  or  it  may  detect  fluid  by  the  sense 
of  fluctuation  it  imparts,  or  a  roughened  serous  membrane  by  the 
friction  fremitus.  When  both  fluid  and  air  are  present  in  a  large 
hollow  space,  by  shaking  the  patient  a  distinct  vibration  of  the 
parietes  is  felt,  accompanied  by  a  splashing  sound,  known  as  the 
Hippocratic  or  succussion  sound. 

Palpation  is  to  be  practised  by  applying  the  palmar  surface  of 
one  or  of  several  fingers  evenly,  and  without  too  much  pressure, 
on  the  part  to  be  examined. 

PEPvCTISSIOS\ 

By  percussing  or  striking  bodies  we  elicit  sounds  by  which  we 
judge  of  their  composition.  That  a  solid  body  emits  sounds  differ- 
ent from  a  hollow  one,  has  been  familiar  to  every  artisan  from 
time  immemorial;  but  the  application  of  this  well-known  fact  to 
the  study  of  the  diseases  of  the  human  frame  was  a  discovery  of 
Avenbrugger,  a  Viennese  physician  of  the  last  century.  He  and 
the  brilliant  editor  of  his  work,  Corvisart,  practised  percussion 
by  striking  directly  with  the  hand  over  the  organs  to  be  ex- 
plored ;  a  method  which,  although  serviceable  to  ascertain  marked 
differences,  or  to  obtain  an  idea  of  the  general  resonance  of  a  part, 
is  inferior  to  the  one  introduced  by  Piorry,  of  mediate  percussion. 
The  media  used  to  receive  the  blow  are  various :  a  disk  or  plate 
of  ivory,  of  wood,  or  of  leather ;  a  piece  of  india-rubber ;  or  the 
middle  finger  of  the  left  hand.  The  finger  answers  best  for  per- 
cussion of  the  chest;  for  abdominal  percussion  a  plexi meter  is 
preferable. 


228 


MEDICAL    DIAGNOSIS. 


Fig.  15. 


AY  hen  the  finger  is  employed,  it  ought  to  be  applied  with  its 
palmar  surface  firmly  pressed  against  the  chest,  and  as  parallel  as 
possible  to  the  ribs.  One  or  two  fingers  of  the  other  hand  may 
then  be  used  to  tap  with, — for  the  finger  is,  for  ordinary  purposes, 
better  than  any  of  the  percussion  hammers  invented, — the  greatest 
attention  being  paid  to  the  circumstance  that  the  percussing  finger 
strikes  perpendicularly,  whatever  pleximeter  be  used,  and  not 
slantingly,  as  is  too  generally  done.  The  whole  movement  should 
proceed  from  the  wrist,  and  only  from  the  wrist,  and  ought  not 

to  be  too  rapid,  or  unequal, 
or  of  great  force.  If  all 
of  these  apparently  un- 
important points  are  at- 
tended to,  the  results  ob- 
tained may  be  relied  upon  ; 
if  not,  the  want  of  manual 
dexterity  invalidates  the 
conclusions.  Xo  fault  is 
so  often  committed  by  the 
beginner  as  the  raising  of 
the  finger  used  as  a  plex- 
imeter from  the  surface, — thus  obtaining  the  sound  of  the  finger, 
and  not  that  of  the  organ  he  wishes  to  percuss, — unless  it  be  the 
fault  of  striking  with  great  force,  as  if  the  object  were  to  break 
into  the  cavity  of  the  chest.  Forcible  percussion  is  of  use  only 
when  the  sound  of  deep-seated  organs  is  to  be  brought  out. 

The  main  sounds  elicited  by  percussion  may  be  designated  as 
dull,  clear,  and  tympanitic.  Of  course  these,  like  all  other 
sounds,  may  differ  in  strength,  in  duration,  and  in  pitch. 

A  dull  sound  denotes  absence  of  air.  It  is  the  sound  both  of 
fluids  and  of  solids.  It  is,  thus,  the  sound  sent  forth  from  the 
airless  viscera, — from  the  liver,  spleen,  and  heart.  When  it 
takes  the  place  of  the  pulmonary  sound,  it  bespeaks  consolida- 
tion, from  whatever  cause  induced,  or  the  presence  of  something 
which  checks  the  normal  vibrations  of  the  lung-texture.  Dulness 
is  always  associated  with  an  increased  sense  of  resistance  to  the 
percussing  finger,  and  over  parts  emitting  it  the  vibrations  of  the 
tuning-fork,  which  Bass  has  introduced  into  diagnosis,  are  weak, 
while  they  are  loud  over  normal  pulmonary  structure. 


The  pleximeter ;  about  natural  size.     It  may  be 
conveniently  made  of  hard  rubber. 


DISEASES    OF    THE    LUNGS. 


229 


A  clear  sound  is  produced  by  a  series 
of  marked  and  unhindered  vibrations 
which  are  emitted  from  a  substance 
containing  air.  As  thus  defined,  a 
clear  sound  evidently  is  yielded  by 
percussing  any  air-containing  organ. 
But  custom  has  restricted  the  employ- 
ment of  the  term  clear  to  denote  the 
peculiar  resonance  obtained  by  striking 
over  pulmonary  tissue.  When,  there- 
fore, a  clear  sound  is  spoken  of,  it 
means  a  sound  having  the  nature  of 
that  of  the  lungs,  or  of  normal  vesicu- 
lar or  pulmonary  resonance. 

A  tympanitic  sound,  on  the  other 
hand,  is  a  non-vesicular  sound,  having 
the  character  of  that  of  the  intestine. 
Wherever  heard,  it  indicates  the  pres- 
ence of  quantities  of  air  in  conditions 
similar  to  that  contained  in  the  intes- 
tine, namely,  enclosed  in  walls  which 
are  yielding,  but  neither  tense  nor  very 
thick.  When  elicited  over  the  chest, 
it  may  be  only  the  transmitted  sound 
of  a  distended  stomach  or  colon.  But 
generally  a  tympanitic  sound  over  the 
seat  of  the  lungs  is  expressive  of  em- 
physema or  of  pneumothorax,  or  some- 
times of  a  cavity  or  of  oedema  of  the 
lungs.  Again,  as  Skoda  has  taught 
us,  it  occurs  in  moderate  pleural  effu- 
sions above  the  level  of  the  liquid. 
Many  find  difficulty  in  distinguishing 
between  the  clear  sound  of  the  pul- 
monary   tissue    and     the     tympanitic 


Fig.  16. 


Fig.  16. — A  serviceable  model  of  a  percussion  hammer; 
not  quite  natural  size.  The  india-rubber  is  screwed  to  the 
ring,  which  has  a  diameter  of  five-eighths  to  three-quarters 
of  an  inch.  The  metallic  ring  is  attached  to  a  steel  stem 
with  a  very  decided  spring.  The  pointed  portion  of  the 
india-rubber  is  used  to  strike  with  on  the  pleximeter. 


230  MEDICAL    DIAGNOSIS. 

sound.  The  more  ringing  character  of  the  latter,  and  its  higher 
pitch,  constitute  its  essential  properties. 

As  modifications  of  the  tympanitic  sound  may  be  viewed  the 
amphoric  or  metallic  sound,  and  the  cracked-pot  or  cracked-metal 
sound.  The  first  of  these  is  a  concentrated  tympanitic  sound  of 
raised  pitch,  and  denotes  a  large  cavity  with  firm,  elastic  walls. 
The  second  is  not  unfrequently  found  associated  with  it.  It  re- 
quires for  its  development  a  strong,  abrupt  blow  of  the  percussing 
finger  while  the  patient  keeps  his  mouth  open.  The  condition 
most  usually  occasioning  the  sound  is  a  cavity  communicating  with 
a  bronchial  tube.  It  is  also  met  with  uncombined  with  an  exca- 
vation, as  in  the  bronchitis  of  children,  in  pleurisy  above  the  seat 
of  effusion,  near  a  pericardial  exudation,  in  emphysema,  and  in 
certain  instances  of  pneumothorax.  Indeed,  any  disorder  in  which 
the  chest-walls  remain  very  yielding,  and  in  which  a  certain 
amount  of  air  contained  in  the  lung  or  pleura  and  in  uninter- 
rupted connection  with  the  external  air  is,  by  sudden  percussion, 
forced  into  a  bronchial  tube,  will  occasion  this  cracked-metal 
sound. 

In  addition  to  the  character  of  all  these  sounds,  we  study  their 
degree,  or  amount  of  fulness  :  such  changes  as  are  expressed  by 
"more  or  less,"  "diminished  or  increased."  Thus,  a  clear  sound 
may  be  increased,  owing  to  stronger  vibrations  and  a  larger  quan- 
tity of  air,  yet  not  lose  its  distinctive  pulmonary  character,  as 
happens  often,  for  instance,  when  the  air-cells  are  dilated;  the 
sound  of  the  large  intestine  is  fuller,  more  tympanitic,  than  that 
of  the  small  intestine,  and  so  forth. 

With  changes  in  fulness  or  volume  of  sound  go  hand  in  hand 
changes  in  its  pitch.  Increased  volume  is  linked  to  lowered  pitch, 
diminished  volume  to  higher  pitch;  but  so  is  increased  tension. 

To  sum  up  the  chief  results  of  percussion,  as  above  described  : 

Quality,  or  Character  of  Sound. 

Clear  : — Presence  of  air, — as  in  the  lung-tissue. 
Dull  : — Solidification  or  compression. 

Tympanitic  : — Certain  amount  of  air  enclosed  in  a  structure  or  cavity  the 
walls  of  which  are  not  too  tense. 
Metallic: — Large  hollow  space,  with  firm  but  elastic  walls. 
Cracked-metal  sound : — Usually  a  cavity  communicating  with  a  bron- 
chus. 


DISEASES    OF    THE    LUNGS.  231 

Degree,  or  Intensity. 

Any  of  the  sounds  mentioned  may  be  diminished  or  increased  in  intensity  as 
the  conditions  which  produce  them  are  modified. 

Pitch. 
Heightened  or  lowered  as  amount  of  air  or  as  tension  is  altered. 

If  it  be  desirable  to  obtain  a  more  distinct  idea  of  the  sound 
than  can  be  done  by  the  ordinary  method  of  practising  percus- 
sion, it  may  be  accomplished  by  resorting  to  auscultatory  percus- 
sion,— a  method  introduced  by  Cammann  and  Clark,  and  which 
consists  in  listening,  with  a  stethoscope  applied  to  the  parietes, 
to  the  sounds  elicited  by  percussion.  It  is  a  serviceable  means 
of  determining  with  accuracy  the  boundaries  of  various  organs, 
as  of  those  of  the  lungs  or  heart,  or  of  the  liver  or  spleen,  and 
yields  particularly  exact  results  when  carried  out  with  the  double 
stethoscope. 

The  percussion  sound  will  also  be  found  to  Vary  with  the  re- 
spiratory movement,  and  useful  information  may  be  obtained  by 
the  appreciation  of  the  note  elicited  by  percussion  while  the  breath 
is  held  after  a  full  inspiration  or  in  a  prolonged  expiration, — a 
method  of  diagnosis  for  which  I  have  proposed  the  name  of 
respiratory  percussion.* 

As  a  standard  for  comparison  in  disease,  the  results  of  respira- 
tory percussion  in  health  must  be  carefully  determined.  It  will 
be  found  that  in  the  normal  chest,  anteriorly,  a  full-held  inspira- 
tion increases  the  resonance,  makes  the  sound  fuller,  and  raises 
the  pitch ;  but,  making  allowance  for  the  cardiac  region,  the  reso- 
nance below  the  apices  is  relatively  less  increased  on  the  left  than 
on  the  right  side. 

Posteriorly,  we  find  in  the  supra-spinous  fossae,  and  on  a  line 
toward  the  spine,  that  a  full  inspiration  makes  the  percussion 
sound  fuller  and  raises  the  pitch,  especially  on  the  right  side.  In 
the  inter-scapular  and  infra-scapular  regions  the  tone  on  gentle 
percussion  is  distinctly  pulmonary  and  the  pitch  moderately  high. 
On  the  left  side  an  admixture  of  tympanitic  resonance  may  be 
detected,  particularly  in  the  infra-scapular  region.     The  pitch  is 

*  American  Journal  of  the  Medical  Sciences,  July,  1875. 


232  MEDICAL    DIAGNOSIS. 

somewhat  lower  in  the  left  scapular  and  infra-scapular  region 
than  in  the  right.  A  full-held  inspiration  elevates  the  pitch, 
increases  the  resonance  very  much,  and  makes  the  difference 
between  the  sides  less  apparent. 

A  held  and  complete  expiration  greatly  lessens  resonance  and 
lowers  the  pitch  on  percussion. 

The  quality  of  the  percussion  note  during  an  arrested  respira- 
tory movement  is  but  little  changed ;  perhaps  it  is  somewhat  less 
soft,  corresponding  to  the  marked  resistance  to  the  percussing 
finger.  In  a  held  inspiration,  nevertheless,  we  obtain  the  idea  of 
a  greater  mass  of  tone;  in  a  held  expiration,  the  reverse.  In- 
crease in  volume  of  percussion  note  accompanies,  contrary  to  our 
usual  experience,  heightened  pitch;  and  this  is  more  especially 
noticed  in  connection  with  the  slight  change  in  quality  above 
mentioned.  This  anomaly  is  probably  due  to  the  altered  tension 
of  the  structures,  both  lung-texture  and  chest-walls,  during  held 
respiratory  movement. 

These  are  the  chief  facts  connected  with  a  study  of  respiratory 
percussion  in  health.  The  application  to  disease  is  manifold,  as 
we  shall  find  in  the  study  of  emphysema,  of  phthisis,  of  pleurisy, 
and  of  pneumothorax.  But  it  is  with  these  special  affections  that 
we  shall  consider  the  subject  further. 

Percussion  of  the  Healthy  Chest. 

The  sound  elicited  by  striking  a  healthy  chest  differs  in  accord- 
ance with  the  part  percussed.  The  anterior  portion  renders  a 
clearer  sound  than  the  posterior,  on  account  of  the  slighter  thick- 
ness of  the  thoracic  walls.  But  the  pulmonary  resonance  is  not, 
even  anteriorly,  alike  at  all  parts.  The  portion  of  lung  above  the 
clavicle  yields  a  sound  which  becomes  somewhat  tympanitic  as  the 
trachea  is  approached.  Percussion  is  difficult  in  this  region,  as  it 
is  almost  impossible  to  apply  the  finger  or  pleximeter  properly  to 
the  surface;  hence  arise  errors  in  diagnosis  if  too  much  value  be 
attached  to  trifling  differences  between  the  two  sides.  Over  the 
clavicle  the  sound  sent  forth  is  clear  and  pulmonary  at  the  centre 
of  the  bone;  at  its  scapular  extremity  it  is  duller;  toward  the 
sternum  it  becomes  of  higher  pitch,  and  mixed  with  the  sound 
of  the  bone.     In  the  region  bounded  above  by  the  clavicle,  and 


DISEASES    OF    THE    LUNGS.  233 

below  by  the  upper  margin  of  the  fourth  rib,  the  resonance  is 
very  marked.  In  fact,  the  sound  of  this  region  may  be  taken  as 
a  type  of  the  pulmonary  sound :  it  is  very  clear  and  distinct,  and 
but  little  resistance  is  offered  to  the  percussing  finger.  Yet  a 
slight  disparity  generally  exists  between  the  two  sides.  On  the 
right  side  the  sound  is  somewhat  less  clear,  shorter,  and  of  a 
higher  pitch,  than  on  the  left.  From  the  fourth  rib  downward, 
on  the  right  side,  the  resonance  of  the  lung,  on  strong  percussion, 
is  found  to  be  slightly  deadened;  near  the  sixth  rib  the  perfectly 
dull  sound  indicates  that  the  liver  has  been  reached.  On  the 
right  side,  during  full  inspiration,  the  liver  is  pushed  downward 
for  the  space  of  an  inch  or  more;  and  the  dull  sound  on  percus- 
sion begins,  therefore,  lower  down,  and  on  a  line  corresponding  to 
the  displacement  of  the  organ. 

On  the  left  side  the  heart  deadens  the  sound  from  the  fourth  to 
the  sixth  rib,  and,  in  a  transverse  direction,  from  the  sternum  to 
the  nipple.  This  dull  sound  is  lessened  in  extent  during  inspira- 
tion, and  in  cases  of  emphysema ;  indeed,  under  any  circumstances 
in  which  the  lung  more  completely  covers  the  heart.  Lower  down, 
owing  to  the  liver  reaching  over  to  the  left  side,  and  to  the  pres- 
ence of  the  spleen  and  a  portion  of  the  stomach,  the  sound  ren- 
dered on  percussion  consists  of  a  mixture  of  the  dull  sound  of  the 
solid  viscera  and  of  the  clear  sound  of  the  lung  with  the  tympa- 
nitic sound  of  the  stomach.  The  latter  character  of  sound  pre- 
dominates when  the  stomach  is  empty.  Over  the  upper  part  of 
the  sternum,  to  the  third  rib,  the  percussion  sound  is  slightly  tym- 
panitic ;  at  the  lower  part,  the  heart  and  liver  cause  this  tympanitic 
or  tubular  character  of  sound  to  give  way  to  a  dull  sound. 

Position  exerts  some  influence  on  the  results  of  percussion.  On 
exchanging  the  recumbent  for  the  erect  posture,  the  pitch  of  the 
sound  on  the  front  of  the  chest  is  raised. 

At  the  posterior  portion  of  the  chest  the  sound  varies  materially 
according  to  the  part  percussed.  Directly  on  the  scapulae  the 
sound  is  duller  than  between  the  bones,  or  than  below  their 
inferior  angles.  Beneath  the  scapula?  a  clear  sound  is  emitted  as 
far  as  the  lower  border  of  the  tenth  rib ;  here,  on  the  right  side, 
the  dulness  of  the  liver  begins.  Strong  percussion,  however, 
causes  the  dulness  to  become  manifest  higher  up.  On  the  left 
side,  below  the  angle  of  the  scapula,  the  percussion  sound  may 


234 


MEDICAL    DIAGNOSIS. 


Fig.  17. 


Fig.  18. 


be  tympanitic  if  the  intestine  be  distended  ;  or  it  may  be  ren- 
dered slightly  dull  by  the  spleen.  In  and  under  the  axilla  the 
sound  is  very  clear.  But  on  the  right  side,  at  the  lower  border 
of  the  sixth  rib,  dulness  becomes  perceptible;  at  a  corresponding 
situation  on  the  left  side,  the  sound  is  clear  or  tympanitic  from 
distention  of  the  stomach  ;  and  at  the  ninth  or  tenth  rib,  dulness 
and  a  sense  of  resistance  to  the  finger  disclose  the  presence  of  the 
spleen. 

AUSCULTATION. 

Auscultation,  or  listening  to  sounds,  informs  us  of  the  play 
of  organs,  and  furnishes  us  with  the  most  trustworthy  means  of 
studying  their  action.  It  is  of  signal  service  in  affections  of  the 
chest.  Indeed,  any  one  who  reflects  upon  the  certainty  with  which 
cases  of  thoracic  disease,  which  would  have  set  at  defiance  the  skill 
of  a  Sydenham  or  a  Cullen,  are  now  capable  of  being  detected, 

even     by     comparative     tyros,    will 

gladly  acknowledge  the  heavy  debt  of 

gratitude  we    owe   to  the  genius  of 

Laennec. 

The  method  he  practised  was  the 

mediate,     or     by     the     stethoscope. 

Another  method  has  since   his  time 

grown    up, — the   immediate,   or    the 

direct  application  of  the  ear  to  the 

chest.     For  ordinary  purposes,  this  is 

the  best;  but  where  it  is  desirable  to 

analyze   circumscribed  sounds,  as  in 

diseases  of  the  heart,  the  stethoscope 

is  preferable. 
Stethoscopes  are   made  of  various    materials  iiawksiey's  stethoscope, 

i      o  tjx>  i  /-^  f  i  i  i      w'th  detached  ear-piece. 

and  oi  different  shapes.  One  or  moderate  length, 
with  an  ear-piece  which  fits  the  pavilion  of  the  ear,  and  with  the 
extremity  not  too  much  expanded,  is  to  be  preferred.  The  mate- 
rial is  of  less  importance.  I  like  best  those  of  gun-metal,  intro- 
duced by  Hawksley.  Of  late  years  double  stethoscopes  have  been 
much  employed.  The  ingenious  instrument  invented  by  Cam- 
mann,  of  New  York,  consists  of  two  tubes,  the  extremities  of 
which  are  placed  into  the  ears.      It  possesses  the  advantage  of 


DISEASES    OF    THE    LUNGS. 


235 


rendering  sounds  louder :  its  great  drawback  is  that  it  indis- 
criminately intensities  all  sounds,  whether  in  the  chest  or  not, 
and  its  use  is,  therefore,  at  first  confusing.     A  similar  kind  of 


Fig.  19. 


Fig.  20. 


Alison's  differential  stethoscope. 


The  double  stethoscope. 


stethoscope  is  the  differential  stethoscope  of  Alison,  by  which  each 
ear  receives  simultaneously  the  sound  from  a  different  region. 
In  auscultating,  the  following  rules  are  to  be  borne  in  mind : 
1st.  Place  yourself  and  your  patient  in  a  position  which  is  the 
least  constraining  and  permits  of  the  most  accurate  application 
of  the  ear  or  stethoscope  to  the  surface.  Above  all,  avoid  stoop- 
ing, or  having  the  head  too  low. 

2d.  Let  the  chest  be  bare,  or,  what  is  better,  covered  only  with 
a  towel  or  a  thin  shirt. 


236  MEDICAL    DIAGNOSIS. 

3d.  If  a  stethoscope  be  employed,  apply  it  closely  to  the  sur- 
face, but  abstain  from  pressing  with  it.  This  may  be  obviated 
by  steadying  the  instrument,  immediately  above  its  expanded 
extremity,  between  the  thumb  and  the  index  finger. 

4th.  Examine  repeatedly  the  different  portions  of  the  chest, 
and  compare  them  with  one  another  while  the  patient  is  breathing 
quietly.  Making  him  cough  or  draw  a  full  breath  is,  at  times,  of 
service;  especially  the  former,  when  he  does  not  know  how  to 
breathe. 

Sounds  of  Respiration  in  Health  and  in  Disease. 

The  ear  applied  over  the  trachea  of  a  healthy  person,  and  sub- 
sequently over  the  lungs,  discriminates  two  dissimilar  sounds, 
which  may  be  severally  taken  as  starting-points. 

The  first  is  plainly  blowing,  both  in  inspiration  and  in  expira- 
tion. It  is  heard  over  the  larynx  and  trachea;  and  in  a  slightly 
modified  form,  as  a  less  intense  and  hollow  sound,  at  the  upper 
part  of  the  sternum ;  and  sometimes,  owing  to  the  closeness  of 
large  bronchial  tubes  to  the  surface,  it  is  perceived  between  the 
scapula?,  on  a  level  with  their  ridges.  It  is  occasioned  by  air 
passing  through  the  tubes,  and  is  known  as  the  tubular  or  the 
bronchial  sound. 

The  sound  over  the  lung-tissue  is  different:  it  is  much  softer, 
more  gradually  formed,  of  lower  pitch,  mainly  inspiratory,  and 
almost  immediately  followed  by  a  shorter  and  far  less  distinct  ex- 
piration. This  is  the  vesicular  murmur, — produced  in  the  finest 
bronchial  tubes  and  air-cells  by  their  expansion  and  contraction. 
The  expansion  gives  rise  to  the  distinct  breezy  inspiration  ;  the 
noiseless  contraction  of  the  elastic  walls  of  the  vesicles  and  the 
passage  of  air  back  into  the  smaller  bronchial  tubes  cause  the 
short,  indistinct,  sometimes  almost  inaudible  expiration.  But  the 
vesicular  murmur  is  not  exactly  alike  at  different  parts  of  the 
lungs.  It  is,  as  a  rule,  better  marked  over  the  upper  lobes  than 
over  the  lower,  and  more  clearly  defined  anteriorly  than  posteriorly. 
Nor  is  the  sound  of  the  two  lungs  precisely  the  same ;  a  disparity 
may  generally  be  noticed  at  the  apices.  Most  authors  describe  the 
vesicular  murmur  as  more  intense  on  the  right  side.  Investiga- 
tions instituted  to  determine  this  point  lead  me  to  agree  with  Dr. 
Flint  that  the  reverse  is  the  case.     More  expiration,  a  higher  pitch, 


DISEASES    OF    THE    LUNGS.  237 

therefore  more  of  the  bronchial  element,  is  presented  by  the  upper 
portion  of  the  right  lung.  But  a  stronger,  more  vesicular  inspi- 
ration belongs  to  the  left  luno;. 

The  murmur  of  the  air-cells,  then,  is  the  sound  which  the  ear 
encounters  when  it  is  placed  over  the  greater  part  of  the  chest. 
Bronchial  respiration  is  constantly  engendered  in  the  tubes  of  the 
lung :  but  either  because  it  is  overpowered  by  the  sounds  of  the 
myriads  of  expanding  air-vesicles;  or  because  the  pulmonary  tissue 
is  a  bad  conductor  for  a  deep-seated  sound ;  or  perhaps  because  the 
sound  requires  consolidated  tissue  for  its  perfect  production, — 
bronchial  breathing  is  not  heard  over  the  chest,  except  at  the  very 
limited  space  indicated,  unless  the  action  of  the  air-vesicles  have 
been  suppressed. 

Disease,  however,  gives  rise  not  only  to  changes  as  absolute  as 
suppression  of  the  vesicular  murmur  and  its  substitution  by  a 
bronchial  respiration,  but  also  to  certain  modifications  of  the  mur- 
mur, which  serve  as  valuable  guides  in  the  diagnosis  of  morbid 
conditions  of  the  lung.  Thus,  the  vesicular  murmur  may  be  ab- 
normal in  its  intensity,  or  in  its  rhythm,  or  it  may  have  lost  some 
of  the  elements  of  its  distinctive  character,  such  as  its  softness. 

Changes  in  the  Vesicular  Murmur. — The  changes  of  the 
murmur  which  are  of  importance  may  be  summed  up  as  follows: 

{Increased,  or  puerile  breathing  ; 
Diminished,  or  feeble  respiration  ; 
Absent  respiration. 

{Divided  and  jerking  respiration; 
Alteration  of  length  of  expiration  relatively 
to  inspiration. 

Alteration  in  Character..  <  Harsh  respiration. 

Intensity. — An  increase  of  the  vesicular  murmur  is  called  sup- 
plementary respiration,  or,  from  its  resemblance  to  the  breathing 
of  children,  puerile  respiration.  It  depends  upon  an  increased 
action  of  the  air-vesicles ;  more  air,  or  air  with  greater  force, 
entering  them.  The  sound  is  simply  a  loud,  distinctly  vesicular 
respiration ;  both  inspiration  and  expiration  being  augmented  in 
duration  and  loudness,  but  retaining  their  relative  length. 

Puerile  breathing  is  not  in  itself  a  sign  of  any  disease.     It  in- 


238  MEDICAL    DIAGNOSIS. 

dicates  rather  greater  activity  and  energy  of  the  part  over  which 
it  is  heard,  which  activity  makes  up  for  the  deficient  action  of 
other  parts.  In  this  manner  effusions  compressing  one  lung,  one- 
sided deposits,  or  obstruction  of  the  bronchial  tubes  by  secretions, 
necessitate  a  supplementary  respiration  in  the  healthy  portion  of 
the  same  lung,  or  in  the  other. 

A  diminution  of  the  vesicular  murmur,  or  feeble  respiration, 
consists  in  a  lessening  of  the  whole  sound  without  change  in  its 
character.  But  the  relation  of  inspiration  to  expiration  does  not 
remain  the  same  as  in  health.  In  the  large  majority  of  instances 
the  inspiration  suffers  most,  and  the  expiration  does  not  diminish 
in  proportion  :  a  circumstance  explained  by  reference  to  the  states 
which  occasion  the  diminished  vesicular  murmur.  These  are 
varied  ;  but  their  causes  may  be  reduced  to  four. 

1st.  Any  cause  which  obstructs  the  passage  of  air  and  prevents 
it  from  fully  reaching  the  pulmonary  tissue.  Foreign  bodies 
lodged  in  the  trachea  or  bronchi ;  affections  of  the  larynx ;  con- 
siderable thickening  of  the  mucous  membrane  of  a  bronchial 
tube;  its  compression,  or  the  accumulation  in  it  of  secretions,  or 
its  contraction  by  a  spasm, — all  diminish  the  quantity  of  the  air 
and  the  force  with  which  it  reaches  the  vesicles,  and  hence  reduce 
the  strength  of  the  murmur. 

2d.  Deficient  respiratory  action.  This  may  arise  either  from 
general  debility;  or  from  impairment  of  the  nervous  force,  as  in 
paralysis ;  or  from  local  pain,  as  in  pleurisy  or  pleurodynia. 

3d^  Causes  which  interfere  mechanically  with  the  free  expan- 
sion of  the  air-cells.  Pleuritic  effusions,  by  compressing  the  lung- 
tissue,  will  of  course  diminish  the  vesicular  murmur;  so,  too,  will 
morbid  growths,  or  malformation  of  the  chest.  Comparatively 
slight  deposits  in  the  pulmonary  tissue  of  tubercle  or  of  lymph 
obliterate  some  air-cells,  and  prevent  others  from  unfolding,  and, 
by  having  impaired  their  elasticity,  diminish  their  sound.  The 
same  loss  of  elasticity  happens  in  emphysema :  the  overdistended 
cells  cannot  expand  much  more,  they  are  rigid  and  more  or  less 
fixed ;  the  vesicular  murmur  is  therefore  feeble. 

4th.  The  respiratory  murmur  may  be  imperfectly  transmitted 
to  the  ear,  owing  to  intervening  fluids  or  solids.  To  this  category 
belongs  the  enfeebled  murmur  so  constantly  met  with  in  fat 
persons. 


DISEASES    OF    THE    LUXGS. 


239 


Diagram  illustrative  of  the  main  forms  of 
feeble  respiration,  a,  from  distention  of  the 
cells  in  vesicular  emphysema;  6,  from  deposits 
in  the  pulmonary  texture ;  c,  from  a  solid  body 
(d)  lodged  in  a  bronchial  tube,  which  has  led  to 
partial  or,  in  some  spots,  to  complete  collapse 
of  the  air-vesicles. 


As  so  many  conditions  occasion  a  feeble  respiratory  murmur, 

it  is  only  by  association  with  other  phenomena  that  it  acquires 

much   importance.     Taking   the 

.  ,  •  ,       i  -,    .  Fig.  21. 

diseases   in   which   the  sound   is 

most  frequently  found,  it  may 
be  stated  that  if  a  feeble  mur- 
mur be  combined  with  dulness 
on  percussion,  it  signifies  a  tuber- 
cular deposit,  or  a  pleuritic  ef- 
fusion :  the  former,  if  at  the 
upper,  the  latter,  if  at  the  lower 
part  of  the  lung.  If  it  be  con- 
nected with  increased  clearness 
on  percussion,  distention  of  the 
air-cells  is  its  cause.  A  vesic- 
ular murmur,  feeble  throughout 
both  lungs,  with  the  percussion 
sound  unaltered,  arises  from  gen- 
eral debility,  or  from  obstruction  of  the  upper  air-passages.  Where 
the  feebleness  of  the  murmur  is  found  to  change  from  place  to 
place,  it  is  dependent  upon  a  loose  foreign  body  which  is  shifting 
its  position  in  the  bronchial  tubes.  Joined  to  unwillingness  to 
expand  the  lung  (on  account  of  the  pain  thereby  brought  on), 
feeble  respiration  denotes  pleurodynia  or  commencing  pleurisy. 

An  absence  of  the  vesicular  mui^mur  is  produced  by  the  same 
causes,  carried  a  step  further,  which  occasion  feeble  respiration. 
Complete  obstruction  of  the  tubes  by  foreign  bodies,  extensive 
deposits  in  the  pulmonary  tissue,  or  its  compression  by  large  pleu- 
ritic effusions,  arrest  the  vesicular  murmur.  But,  practically 
speaking,  there  is  only  one  complaint  in  which  we  are  apt  to  find 
it  entirely  wanting,  and  that  is  when,  associated  with  flatness  on 
percussion,  the  presence  of  a  large  collection  of  fluid  in  the  pleura 
is  attested.  Extensive  deposits  in  the  lung-tissue,  tubercular  or 
lymphous,  also  suppress  the  sound  of  the  air-cells ;  but  they  do 
not  suppress  all  sound.  The  noise  of  the  tubes,  the  bronchial 
respiration,  then  takes  the  place  of  the  vesicular  murmur,  and 
denotes  the  perfect  consolidation  of  the  pulmonary  tissue. 

Rhythm. — The  inspiration  and  the  expiration  may  be  altered  as 
regards  their  rhythm.     The  inspiration  may  be  broken  up  into 


240  MEDICAL    DIAGNOSIS. 

little  puffs, — jerking  respiration  ;  or  both  inspiration  and  expira- 
tion may  be  lengthened  or  shortened.  But  neither  lengthening 
nor  shortening  of  the  inspiratory  murmur  has  a  distinct  clinical 
value;  and  jerking  inspiration,  met  with  as  it  is  in  spasmodic 
affections,  in  hysteria,  in  pleurodynia,  and  in  tubercular  infiltra- 
tions, is  present  under  too  many  different  circumstances  to  have 
by  itself  much  diagnostic  significance.  But  if  limited  to  the 
apex,  it  may  serve  to  excite,  or  aid  in  corroborating,  a  suspicion 
of  tubercular  deposit.  One  modification  of  the  rhythm  is,  how- 
ever, of  decided  importance, — a  marked  increase  in  the  duration 
of  the  expiratory  murmur  while  the  patient  is  breathing  quietly. 

Prolonged  expiration  denotes  that  the  air  has  difficulty  in  get- 
ting out  of  the  lung.  It  is  detained  in  consequence  either  of  loss 
of  elasticity  of  the  cells,  or  of  an  obstruction  in  the  bronchi. 
The  former  state  may  be  occasioned  by  overdistention  of  the  air- 
vesicles,  as  in  emphysema,  or  by  deposits  which  impair  their  con- 
tractile power.  In  the  first  case,  the  prolonged  expiration  is 
associated  with  augmented  clearness  on  percussion  ;  in  the  second, 
with  impaired  clearness.  Where  the  prolonged  expiration  is  met 
with  at  the  apex  of  the  lung,  in  connection  with  dulness,  it  is  for 
the  most  part  caused  by  a  tubercular  deposit. 

But  a  prolonged  expiration  from  tubercular  or  from  any  other 
kind  of  infiltration  is  not  simply  the  pure,  prolonged  expiration  of 
deficient  elasticity  of  the  air-cells.  It  is  something  more.  The 
solid  material  conducts  a  portion  of  the  sound  of  the  bronchial 
tubes  to  the  ear;  and  bronchial  breathing  is  nearly  always  best 
and  earliest  perceived  in  expiration.  Thus,  a  prolonged  expira- 
tion, when  joined  to  dulness  on  percussion  and  to  an  inspiration 
still  vesicular,  is  a  sound  partly  vesicular,  partly  bronchial,  and 
may  be  interpreted  as  consolidation  of  the  lung-tissue;  consolida- 
tion not  sufficient  to  have  obliterated  all  the  air-cells,  but  sufficient 
to  have  obliterated  some,  and  to  have  impaired  the  contractile 
power  of  others. 

The  obstacle  to  the  exit  of  the  air  may  reside  wholly  in  the 
bronchial  tubes.  Such  is  the  source  of  the  prolonged  expiration 
when  the  mucous  membrane  of  the  bronchi  is  swollen.  Not  only 
does  this  condition  cause  the  air  to  be  retained  longer  in  the  air- 
cells,  but  the  resistance  to  the  exit  of  the  column  of  air  brings 
out  more  of  the  bronchial  sound.     On  the  whole,  then,  an  accu- 


DISEASES    OF    THE    LTJXGS.  241 

rate  study  of  the  expiration  is  of  decided  value;  and  it  is  of 
great  importance  to  impress  on  young  auscultators  the  advantage 
of  inquiring  into  the  expiration  separately  from  the  inspiration. 

Character. — A  distinctive  character  of  the  vesicular  murmur  is 
its  softness.  From  the  moment  it  loses  this,  it  begins  to  pass  into 
the  bronchial  sound.  Respiration  which  is  wanting  in  softness  is 
termed  harsh  respiration,  or,  to  modify  slightly  a  term  introduced 
by  Dr.  Flint,  vesiculo-bronchial.  Harsh  breathing  is,  in  truth,  a 
union  of  the  vesicular  and  the  bronchial  sounds ;  it  is  a  vesicular 
sound  mixed  with  some  of  the  qualities  of  a  bronchial  sound, — a 
rough  inspiration  devoid  of  all  the  softness  of  the  normal  respi- 
ratory murmur,  with  a  prolonged,  somewhat  blowing  expiration. 
Any  affection  which,  without  destroying  the  murmur  of  the  vesi- 
cles, causes  the  sound  in  the  bronchial  tubes  to  be  produced  with 
greater  intensity,  or  to  be  better  transmitted,  will  occasion  harsh 
breathing:.  Thus,  it  exists  when  the  bronchial  membrane  is 
swollen,  as  in  bronchitis,  and  still  more  frequently  in  diseases 
which  are  attended  with  compression  of  the  lung-tissue,  or  with 
partial  condensation,  such  as  some  stages  of  the  forms  of  phthisis 
or  of  pneumonia.  Being  a  transition  murmur  to  bronchial,  harsh 
respiration  shares  the  properties  of  the  latter  in  having  its  expira- 
tion more  developed  than  its  inspiration.  It  is  true,  the  inspira- 
tion alone  may  be  harsh,  and  the  expiration  not  be  much  changed; 
but  this  is  uncommon. 

Harsh  respiration  may  be  confounded  with  puerile  respiration, 
with  sonorous  rales,  and  with  bronchial  breathing.  From  the  first 
it  varies  by  its  higher  pitch,  its  roughness,  its  more  distinct  and 
blowing  expiration  ;  from  sonorous  rales,  with  which,  however,  it 
often  coexists,  by  the  absence  of  all  vibrating  or  musical  character. 
From  bronchial  respiration  harsh  respiration  differs  merely  by 
degrees :  it  is  mixed  with  more  of  the  vesicular  sound,  is  less 
blowing  in  inspiration,  and,  when  produced  by  condensation,  is 
not  associated,  owing  to  the  smaller  amount  of  deposit  giving  rise 
to  it,  with  so  much  dulness  on  percussion. 

Bronchial  Respiration. — Purely  bronchial  respiration  may 
exhibit  the  same  modifications  as  the  vesicular  murmur  in  respect 
to  rhythm  and  intensity.  But  neither  its  rhythni  nor  its  intensity 
is  of  sig-nificance  :  its  character  is.  To  hear  well-defined  bronchial 
respiration  is,  in  the  majority  of  cases,  to.  meet  with,  complete 

16 


242  MEDICAL    DIAGNOSIS. 

consolidation  of  the  pulmonary  tissue.  It  is  thus  that  in  extensive 
infiltrations  and  in  hepatization  of  the  lung  we  find  the  bronchial 
or  blowing  breathing  so  marked;  particularly  so  in  the  latter 
morbid  state,  for  the  most  distinctly  blowing  or  tubular  respiration 
is  heard  in  pneumonia. 

The  bronchial  breathing  encountered  in  disease  resembles  more 
that  heard  in  health  over  the  larynx  or  trachea,  than  that  heard 
over  the  larger  bronchial  tubes.  It  entirely  replaces  the  vesicular 
sound,  which 'has  for  the  time  being  ceased  to  exist.  It  differs 
from  the  normal  vesicular  murmur  by  its  higher  pitch  ;  by  its 
occurrence  equally  in  inspiration  and  in  expiration;  by  its  blow- 
ing character,  especially  in  expiration;  and  by  the  pause  between 
inspiration  and  expiration.  Harsh  respiration  resembles  it  most; 
but  this  or  vesiculobronchial  respiration  is,  as  already  stated,  a 
transition  from  vesicular  to  bronchial  breathing. 

Whether  bronchial  respiration  be  owing,  as  Laennec  taught,  to 
a  better  transmission  of  the  sound  of  the  tubes  through  the  solid 
lung;  or  whether  it  be  produced,  as  Skoda  declares,  by  conso- 
nance,— is  not  of  much  consequence  for  diagnosis.  The  important 
practical  fact  connected  with  this  form  of  respiration  is,  that  it 
happens  when  the  pulmonary  tissue  is  condensed,  which,  in  the 
large  majority  of  cases,  takes  place  from  exudations  or  deposits ; 
in  a  small  proportion  only,  from  compressions  by  growths  or 
effusions. 

A  variety  of  bronchial  respiration,  at  least  so  far  as  the  quality 
of  the  sound  determines  the  point,  is  that  significant  sign,  cavern- 
ous respiration.  This  is  essentially  a  blowing  sound  ;  yet  it  is  not 
alwavs  distinct  during  both  inspiration  and  expiration,  being  often 
only  perceptible  in  the  one,  and  mixed  in  the  other  with  gurgling. 
The  question  whether  it  can  always  be  distinguished  from  bron- 
chial breathing  has  given  rise  to  much  dispute.  That  cavities 
may  exist  without  cavernous  respiration  being  perceived,  op,  on  the 
other  hand,  that,  owing  to  peculiar  physical  conditions,  cavernous 
respiration  may  have  been  heard  where  no  cavities  were  present, 
cannot  be  denied.  But  that  a  sound  is  met  with  which  is  less 
diffused,  much  more  hollow,  and,  above  all,  of  much  lower  pitch 
than  ordinary  bronchial  respiration;  that  connected  with  it  other 
signs  of  a  cavity  are  found;  and  that,  under  such  circumstances, 
a  post-mortem  examination  proves  an  excavation  to  have  existed 


DISEASES    OF    THE    LUNGS.  243 

at  the  spot  where  during  life  the  sound  was  detected, — are  facts 
which  equally  cannot  be  denied.  The  peculiar  sound  occurs,  and 
may  be  discerned  by  the  ear ;  and  no  theory,  however  cautious  it 
may  make  us  in  our  conclusions,  can  put  aside  the  evidence  of  the 
senses. 

Cavernous  respiration  is,  then,  a  blowing  sound  of  low  pitch, 
circumscribed,  alternating  with  gurgling,  and  deriving  its  chief 
character  from  the  cavity  in  which  it  is  formed.  Hollow  spaces 
of  any  kind — from  abscesses,  from  bronchial  dilatation,  from 
breaking-down  cheesy  degeneration,  from  softening  tubercle — give 
rise  to  it.  How  it  is  to  be  distinguished  from  bronchial  respira- 
tion has  already  been  indicated.  A  student  learns  this  sooner 
than  he  does  to  discriminate  between  cavernous  breathing  and  the 
vesicular  murmur ;  the  best  proof  that  the  ear  recognizes  a  differ- 
ence between  bronchial  and  cavernous  respiration,  since  the  latter, 
as  a  sound  of  lower  pitch,  is  more  like  the  vesicular  murmur.  It 
is  only  necessary  to  recall,  with  reference  to  the  distinction  from 
the  sound  of  the  air-cells,  that  this  murmur  is  devoid  of  all 
blowing  quality. 

Amphoric  respiration  is  a  blowing  respiration  engendered  in  a 
large  cavity  with  firm  walls.  Its  peculiar  character  is  owing  to 
an  echo  from  the  walls  of  the  cavity.  It  may  be  humming  and 
of  low  pitch,  or  decidedly  ringing  and  metallic.  An  imitation  of 
the  sound,  though  only  an  imj)erfect  one,  is  effected  by  blowing 
into  an  empty  jar. 

Amphoric  or  metallic  respiration  is  always  indicative  of  a  large 
cavity ;  the  sound  is  rarely  met  with  in  phthisis ;  much  oftener  is 
it  heard  over  the  cavity  which  is  formed  between  the  layers  of  the 
pleura,  by  the  entrance  of  air. 

Another  variety  of  breathing  connected  with  a  cavity  is  the 
so-called  metamorphosing  breath  sound,  to  which  Seitz  has  called 
attention.  It  occurs  only  in  inspiration,  and  consists  of  a  very 
harsh  sound,  which  lasts  for  about  one-third  of  the  period  of  in- 
spiration, when  it  is  continued  as  blowing  respiration,  attended 
with  metallic  echo  or  ordinary  rales.  The  cause  of  the  phenome- 
non is  the  air  having  to  enter  through  a  narrow  opening  to  reach 
the  cavity. 

New,  or  Adventitious  Sounds. — These  consist  of  sounds 
which  have  no  analogue  in  the  healthy  state,  and  which  cannot, 


244  MEDICAL    DIAGNOSIS. 

therefore,  be  considered  as  modifications  of  the  normal  respiration. 
Of  this  kind  are  the  rales ;  the  sound  known  as  crackling ;  the 
friction  sound. 

Nearly  all  rales,  or  rhonchi,  are  sounds  which  are  generated  in 
the  air-tubes  by  the  passage  of  air  through  them  when  contracted 
or  when  containing  fluid.  In  the  first  case  are  occasioned  dry,  in 
the  second,  moist  rales.  Rales  may  occur  in  inspiration  or  in 
expiration,  or  during  both  acts.  They  may  obscure  or  entirely 
take  the  place  of  the  natural  murmurs.  They  may  have  their 
seat  in  the  upper  air-tubes,  or  in  any  division  of  the  bronchi. 
"When  in  the  larynx  or  in  the  trachea,  they  are  called  tracheal  rales; 
of  these  the  death-rattle  is  an  example.  When  in  the  bronchial 
tubes,  they  are  designated  bronchial  rales;  and,  as  this  is  their 
most  frequent  situation,  the  term  rale  means  a  bronchial  rale 
unless  the  location  be  specially  indicated. 

Dry  rales  are,  for  the  most  part,  produced  by  the  vibration  of 
thick  fluids  which  the  air  cannot  break  up,  and  which  temporarily 
narrow  the  calibre  of  the  tube.  When  this  narrowing  exists  in 
the  smaller  bronchial  tube,  the  sound  which  results  is  high-pitched, 
— sibilant;  when  in  the  larger,  unless  the  calibre  be  much  al- 
tered, it  is  low-pitched,  more  musical, — sonorous.  A  similar  dif- 
ference is  observed  with  reference  to  the  moist  or  bubbling  sounds. 
When  the  fluid  is  thin,  whether  it  be  mucus,  blood,  or  serum,  and 
breaks  up  into  large  bubbles,  large  bubbling  sounds  are  occasioned; 
when  it  separates  into  small  bubbles,  small  bubbling  sounds  are  the 
consequence.  The  latter,  for  obvious  reasons,  generally  take  place 
in  the  smaller  tubes. 

Neither  dry  nor  moist  rales  are  persistent,  but  vary  in  intensity, 
or  shift  their  position,  as  the  air  drives  the  liquid  which  gives  rise 
to  them  before  it.  Dry  rales  are  particularly  prone  to  be  dislodged 
by  coughing.  When  they  are  uninfluenced  by  the  act  of  breathing 
or  of  coughing,  they  do  not  depend  upon  the  presence  of  secretions, 
but  upon  a  narrowing  of  the  air-tubes  from  the  pressure  of  sur- 
rounding tumors  or  from  a  fold  of  thickened  mucous  membrane, 
or  by  a  spasm. 

It  has  just  been  stated  that  rales  are,  for  the  most  part,  pro- 
duced in  the  bronchi  by  the  passage  of  air  through  fluids  there 
contained.  This  is  their  most  frequent  seat;  but  they  are  not 
limited  to  the  tubes.     Similar  conditions  may  give  rise  to  rales  in 


DISEASES    OE    THE    LUNGS. 


245 


other  places.  We  find  liquids  in  cavities  breaking  up  into  large, 
sharply-defined,  bubbling  rales,  the  so-termed  cavernous  rale, — 
gurgling ;  or  having  in  cavities  of  considerable  size  a  ringing 
metallic  character ;  and  again,  the  presence  of  fluid  in  the  air-cells 
occasions  a  minute  rale, — the  crepitant. 

This  vesicular  rale,  or  crepitation,  is  a  very  fine  sound,  or  rather 
a  series  of  very  fine  uniform  sounds,  occurring  in  puffs,  and 

Fig.  22. 


Large 
bubbling 


Sonorous. 


Sibilant. 


Diagram  illustrative  of  rales.  The  narrowing  in  one  division  of  the  tube  gives  rise  to 
drjr,  the  fluid  in  the  other  to  moist  rales.  The  rales  at  the  termination  of  the  tube  and 
in  the  air-vesicles  are  the  crepitant  or  vesicular  rales. 


limited  to  inspiration.  It  resembles  the  noise  occasioned  by 
throwing  salt  on  the  fire.  Its  name  indicates  its  seat.  It  is  caused 
by  the  agitation  of  fluid  in  the  air-cells  or  in  the  finest  extremities, 
of  the  bronchial  tubes;  or,  to  adopt  a  view  now  held  by  many,  by 
the  forcing  open  during  inspiration  of  the  air-cells  agglutinated  by 
the  exuded  lymph.  The  first  stage  of  acute  pneumonia  is  the  state 
in  which  this  rale  is  mostly  engendered. 

The  rales,  including  crackling,  may  be  thus  grouped  : 


246  MEDICAL    DIAGNOSIS. 


Bronchial  Kales. 


f    Dry  or  vibrating  f  Low-pitched  (sonorous), 

sounds.  t  High-pitched  (sibilant). 

Moist  or  bubbling  j  Large  bubbling  (mucous), 

sounds.  I  Small  bubbling  (subcrepitant). 


-r-  -n  f    Crepitation. 

\  K8ICTJTLAB  Kales.    •  * 

(.    Crackling? 

t,  ry  (    Hollow  bubbling:,  or  surg-ling. 

Rale  of  Cavities.  6'      °.  °     ° 

t    Metallic  rales. 

Craohlinf/  is  a  sign  closely  connected  with  rales,  and,  though 
its  mechanism  is  undecided,  it  is  regarded  as  a  rale.  It  consists 
of  a  few  fine  and  readily-discerned  crackling  sounds  which  happen 
generally  in  cases  of  pulmonary  tubercle,  and  of  which,  therefore, 
they  are  considered  as  diagnostic. 

The  distinction  between  crackling  and  the  crepitant  rale  is  one 
most  puzzling  to  a  beginner.  Xor  is  there,  in  reality,  any  differ- 
ence, except  in  the  number  of  the  sounds.  Crackling  is  a  few 
fine  sounds  limited  to  inspiration,  and  heard  commonly  at  the 
apex  of  the  lung.  Crepitation  is  a  number  of  fine  sounds  limited 
to  inspiration,  but  more  diffused,  and  heard  generally  at  the  base 
of  the  lung.  The  sound  is  similar  because  the  conditions  giving 
rise  to  it  are  similar.  Both  depend  upon  tenacious  fluid  or  semi- 
fluid matter  in  the  ultimate  structure  of  the  lung:  in  the  one  case 
it  is  tubercle  or  cheesy  degeneration,  in  the  other  usually  the 
lymph  of  beginning  inflammation.  The  crackling  which  indi- 
cates softening,  as  of  tubercle, — called  by  some  authors  moist 
crackling,  by  others  clicking, — is  a  succession  of  sounds  like  small 
moist  rales,  only  less  liquid  than  these,  because  breaking-up  tuber- 
cle is  not  very  fluid.  The  fine  or  dry  crackling  of  the  earlier 
stages  of  phthisis  corresponds,  then,  to  a  vesicular  rale;  the 
coarser,  or  moist  crackling,  to  the  small  bubbling  sound.  When 
the  bubbles  become  larger  and  larger,  and  cavities  form,  and  the 
fluid  matter  in  them  is  agitated  by  the  ingress  and  egress  of  air, 
the  large,  bubbling,  ringing  rale  of  cavities,  or  gurgling,  is  occa- 
sioned. Dry  crackling,  moist  crackling,  and  gurgling  accord  then 
with  the  crepitant  rale,  small  bubbling,  and  large  bubbling  sounds, 
and  happen  in  the  progressive  stages  of  infiltration  and  softening 
of  deposits,  and  generally  in  those  of  a  tubercular  nature. 

Pleural  friction,  or  the  sound  due  to  the  rubbing  together  of 
roughened  pleural  surfaces,  consists  of  a  number  of  abrupt  super- 


DISEASES    OF    THE    LUXGS.  247 

ficial  noises  heard  in  inspiration  and  expiration,  rarely  in  either 
alone.  Its  seat  is  not  usually  extended,  for  it  is,  as  a  rule,  only 
audible  over  portions  of  the  lower  part  of  one  side  of  the  chest. 
Sometimes  it  is  so  creaking  and  intense  as  to  be  distinctly  percep- 
tible to  the  hand  as  well  as  readily  recognizable  by  the  ear.  But 
it  may  be  so  much  like  crepitation  that  even  long  practice  in  aus- 
cultation will  not  enable  us  to  determine  at  once  whether  the  fine 
sounds  we  hear  are  the  friction  of  a  roughened  pleura,  or  the 
vesicular  rales  of  an  inflamed  lung.  It  is  easy  to  lay  down  in 
books  the  distinguishing  mark  of  greater  superficiality ;  but  at 
the  bedside  the  difficulty  remains  the  same,  and  is  removed  only 
by  attention  to  the  physical  signs  and  symptoms  accompanying 
the  doubtful  sounds. 

Nor  is  it,  in  some  cases,  less  perplexing  to  discriminate  between 
fine  friction  sounds  and  fine  moist  rales.  By  the  sound  alone  it 
is  often  impossible;  concomitant  phenomena  must  be  taken  into 
account.  A  friction  sound  is  mostly  confined  to  a  smaller  space, 
and  is  uninfluenced  by  cough ;  while  cough  changes  the  position 
and  the  distinctness  of  rales.  Yet  even  this  rule  is  not  absolute. 
A  fine  friction  sound  may  be  temporarily  increased  during  the 
deep  breathing  which  follows  the  act  of  coughing;  on  the  other 
hand,  the  influence  which  cough  exerts  on  the  small  moist  rale  is 
not  so  great  as  on  the  larger  bubbling  sound.  As  for  the  more 
marked  character  of  moisture  which  a  rale  is  said  to  possess,  that 
only  aids  us  in  some  cases.  Where  the  secretions  are  viscid,  it 
would  require  a  sense  of  hearing  more  delicate  than  belongs  to 
the  majority  of  mankind  to  judge,  by  the  application  of  this  test, 
whether  the  sound  we  perceive  is  formed  in  the  lung  or  on  its 
covering.  As  the  result  of  investigations  undertaken  to  ascertain 
whether  there  is  any  positive  difference,  so  far  as  the  ear  can 
detect,  between  some  of  the  finer  kinds  of  friction  and  fine  moist 
rales,  I  have  come  to  the  conclusion  that  frequently  little  or  none 
exists ;  and  still  less  is  there  between  crackling  and  the  crackling 
variety  of  friction  sound,  or  between  this  and  the  vesicular  rale. 
The  features  most  at  variance  are  :  that  the  friction  phenomena 
are  not  strictly  limited  to  inspiration  as  are  the  vesicular  rales,  are 
not  seldom  coarser  in  expiration  than  in  inspiration ;  that  they  are 
less  uniform;  and  that  their  seat  is  more  circumscribed.  Their 
production  nearer  to  the  ear  may  assist  us,  but  does  not  always. 


248  MEDICAL    DIAGNOSIS. 

The  reason  why  some  of  the  finer  friction  sounds  resemble  so 
closely  fine  moist  rales  or  crepitation  is  apparent  when  Ave  reflect 
that  the  irregularities  in  the  pleura  may  be  slight,  and  be  sur- 
rounded by  fluid  which  keeps  them  moistened.  As  an  additional 
means  of  distinction,  Dr.  Van  Valzah  has  called  my  attention  to 
the  value  of  making  the  chest-walls  immovable.  When  the  chest 
is  fixed,  especially  at  the  lower  two-thirds,  by  the  hand  of  an  as- 
sistant, and  the  ear  or  the  stethoscope  is  applied  over  the  seat  of 
the  doubtful  sounds,  they  will  be  found  to  have  disappeared  if 
of  pleural  origin,  but  to  be  still  discernible  if  rales. 

The  creaking  or  grating  varieties  of  friction  are  much  easier  of 
recognition  than  the  finer  forms.  Their  discrimination  from  rales 
is  readily  effected  by  noticing  the  rubbing  and  harsh  character 
they  possess. 

Auscultation  of  the  Voice. 

Attention  to  the  voice,  as  heard  over  the  chest,  is  by  some  aus- 
cultators  regarded  as  very  important  in  examinations  of  the  lungs. 
The  one,  two,  three,  which  patients  are  made  to  pronounce,  may 
be  almost  daily  heard  resounding  in  clinical  amphitheatres.  Yet 
the  information  derived  from  a  study  of  the  thoracic  voice  is  very 
small,  next  to  valueless,  unless  confirmed  by  other  physical  signs. 

When  the  ear  is  applied  to  the  thorax  of  a  healthy  person  who 
is  speaking,  a  confused  hum  is  perceived,  most  distinct  in  adults 
who  are  possessors  of  a  deep  voice,  and  tremulous  in  the  aged. 
Now,  the  normal  vocal  resonance,  for  by  that  name  the  ill-defined 
vibrations  are  called,  is  more  marked  on  the  right  than  on  the  left 
side,  and  corresponds  to  the  vesicular  murmur.  Over  the  bronchial 
tubes  a  more  concentrated  sound  strikes  the  ear.  This,  termed 
bronchophony,  accords  with  bronchial  respiration,  and,  when  de- 
tected over  the  lung,  denotes,  with  rare  exceptions  hereafter  to  be 
referred  to,  the  same  as  bronchial  respiration, — increased  density 
of  pulmonary  tissue  caused  by  pressure  or  by  deposit.  Any  nor- 
mal vocal  resonance  which  is  augmented  passes  by  degrees  into 
bronchophony,  and  has  a  meaning  similar  to  it. 

Of  the  sound  known  as  bronchophony  there  are  several  varie- 
ties: the  simple  bronchophony  just  explained, — observed  in  pneu- 
monia, or  in  any  form  of  consolidation ;  the  hollow,  cavernous 
voice,  or  pectoriloquy;    and    the  bleating  variety,  or   cegophony. 


DISEASES    OF    THE    LUNGS.  249 

The  latter,  indicative  of  a  thin  layer  of  fluid  between  compressed 
lung  and  the  ear,  is  a  sign  generally  too  transitory  to  be  of  much 
diagnostic  value ;  and  pectoriloquy,  if  by  this  be  understood  what 
Laennec  meant, — complete  transmission  of  articulated  words, — is 
of  no  special  significance,  as  it  may  be  met  with  where  no  cavity 
exists.  But  if  the  term  be  applied  to  a  well-defined  chest-voice, 
of  hollow  character,  and  heard  as  such  over  a  comparatively 
limited  space,  pectoriloquy  is  a  distinct  physical  sign,  and  really 
deserves  the  name  of  cavernous  voice.  This  is  particularly  true  of 
whispering  pectoriloquy.  Over  large  cavities  the  voice  is  pecu- 
liarly ringing  and  metallic.  The  conditions  which  produce  am- 
phoric or  metallic  voice  are  the  same  as  those  which  occasion  any 
of  the  amphoric  or  metallic  phenomena.  Be  the  respiration 
metallic,  be  the  voice  metallic,  be  the  rales  metallic,  they  are  all 
caused  by  a  cavity  large  enough  and  with  walls  firm  enough  to 
reflect,  to  echo  the  sound. 

Bronchophony  and  amphoric  voice  are  instances  of  increase  and 
change  of  character  of  the  normal  vocal  resonance.  A  diminished 
vocal  resonance  occurs  when  the  lung  is  compressed  by  air  or  fluid, 
as  in  pleuritic  effusions,  or  in  pneumothorax ;  or  when  it  is  greatly 
distended  with  air,  as  in  extreme  cases  of  emphysema.  Clinically 
speaking,  the  sign  is  most  frequently  encountered  in  pleuritic 
effusions. 

The  vibrations  of  the  voice  may  be  felt  as  well  as  heard.  The 
vibration  detected  by  placing  the  hand  over  the  thorax  when  the 
patient  speaks,  or,  to  designate  it  by  the  name  it  bears,  the  vocal 
fremitus,  is,  like  the  voice,  increased  by  all  consolidations  of  pul- 
monary tissue,  and  diminished  by  fluid  or  air  in  the  pleura.  Its 
relations  to  the  voice  are,  however,  not  uniform ;  and  sometimes 
with  increased  density  of  the  lung-tissue  there  is  no  increased 
fremitus,  although  there  is  increased  chest-voice.  In  women  the 
sign  is  valueless;  indeed,  its  main  importance  is  derived  from  its 
absence  in  cases  of  pleuritic  effusions.  Just  as  the  voice,  it  is  most 
marked  on  the  right  side. 

Rales,  when  extensive,  sometimes  cause  a  vibration  to  be  trans- 
mitted to  the  chest-walls,  as  do  the  fluids  in  cavities.  The  former 
phenomenon  is  called  the  bronchial  fremitus,  the  latter  the  cavern- 
ous fremitus.  A  friction  sound  that  may  be  felt  is  designated  as 
the  pleural  fremitus. 


250  MEDICAL    DIAGNOSIS. 

The  Combination  of  the  Physical  Signs,  and  the  Examination 
of  Patients  affected  with  Disease  of  the  Lungs. 

In  the  preceding  pages  isolated  physical  signs  have  been  dis- 
cussed. But  if  in  the  investigation  of  disease  we  were  to  trust 
solely  to  isolated  signs,  incomplete  and  unsatisfactory  indeed  would 
be  our  conclusions.  All  the  methods  of  physical  exploration  must 
be  employed,  the  results  obtained  compared  with  one  another, 
and  the  attending  symptoms  carefully  inquired  into  and  brought 
into  connection  with  the  physical  signs,  before  a  diagnosis  is  made, 
or  a  treatment  instituted. 

A  patient  presents  himself  for  examination.  After  having 
obtained  the  history  of  the  case,  it  is  well  to  look  at  his  general 
appearance;  to  scan  the  expression  of  his  countenance  ;  to  feel  the 
skin  and  the  pulse ;  to  inquire  into  the  nature  of  the  cough  and  of 
the  expectoration;  and  to  determine  the  existence  of  pain.  The 
character  and  frequency  of  the  breathing  are  noted.  Next  we  pro- 
ceed to  a  physical  exploration.  The  chest  is  watched;  its  move- 
ments, its  size  are  inspected, — if  necessary,  measured.  Percussion 
is  employed,  then  auscultation. 

The  manner  of  investigating  by  these  methods  has  been  detailed  ; 
it  need  not  here  be  repeated.  But  what  may  be  repeated  is,  that 
there  are  two  lungs;  that  it  is  incumbent  always  to  explore  both, 
and,  as  we  proceed,  to  compare  the  action  of  one  with  that  of  the 
other.  Nor,  even  when  the  pulmonary  affection  has  been  made 
out,  ought  the  examination  to  be  stopped.  The  state  of  other 
organs  and  of  the  system  must  be  inquired  into,  so  as  not,  in 
the  pursuit  of  a  few  physical  signs  in  the  lung,  to  pass  by  accom- 
panying disorders  of  the  heart,  or  liver,  or  stomach ;  so  as  not  to 
overlook  vital  conditions,  compared  with  which,  as  respects  the 
treatment,  the  physical  phenomena  often  sink  into  insignificance. 
There  are  acute  and  chronic  diseases  of  the  lung.  The  physical 
signs  of  both  may  be  the  same ;  but  the  general  symptoms  and 
the  constitutional  state  attending  them  are  not  always  identical. 
In  truth,  these  are  at  times,  in  the  same  malady,  so  different  as  to 
render  a  remedy  which  is  of  use  in  one  case,  useless  or  worse  than 
useless  in  another. 

As  many  of  the  signs  elicited  by  the  various  methods  of  phys- 
ical diagnosis  depend  on  the  same  physical  conditions,  they  may  be 


DISEASES    OF    THE    LUNGS. 


251 


studied  in  groups, 
associated : 


The  following  will  be  usnallv  found  to  be 


Association  of  Physical  Sigxs. 


Percussion. 


Auscultation  of 
Respiration. 

Clear Vesicular 

murmur  or 
its  modifi- 
cation. 
('Bronchial, 
I      or  harsh 

Dull 1      respiration. 

|  Absent  respi- 
L     ration. 


Auscultation 

of  Voice. 

Normal  vocal 

resonance. 


Vocal  Fremitus. 
"Unimpaired. 


Physical  Condition. 


Bronchophony.       Increased. 


Tympanitic, 


Cavernous  or 
feeble,  accord- 
ing to  cause. 


Absent  voice. 

Uncertain ; 
cavernous  or 
diminished. 


Amphoric  or    Amphoric  or  Amphoric  or 

metallic...         metallic.  metallic. 

Cracked  metal  Cavernous  Cavernous 

sound respiration.  voice. 


Diminished  or 
absent. 

Uncertain ; 
mostly  di- 
minished. 


Mostly  dimin- 
ished. 
Uncertain. 


Lung-tissue  healthy  or  nearly 
so ;  at  any  rate,  no  increased 
density  of  lung-tissue  from 
deposit  or  from  pressure. 

Solidification  of  pulmonary 
structure. 

Effusion  into  pleural  sac. 

Increased  quantity  of  air  with- 
in the  chest,  or  air  confined 
ill  particular  points ;  slates 
commonly  due  to  a  cavity, 
or  to  overdistention  of  the 
air-cells. 

Large  cavity  with  elastic  walls. 

Generally  a  cavity  communi- 
cating with  a  bronchial  tube. 


In  adults  these  phenomena  are  commonly  combined.  In  chil- 
dren, however,  their  connection  is  not  so  constant  or  so  apparent. 
Owing  to  the  extreme  elasticity  of  the  thoracic  walls  and  the 
naturally  clearer  sound  of  the  lungs,  the  relations  of  percussion 
to  auscultation  are  not  the  same  as  in  the  adult.  Dulness,  even 
where  the  condition  exists  for  its  production,  is  rarely  as  marked ; 
nor  is  comparison  between  the  two  sides  of  the  chest  as  valuable, 
since  most  of  the  acute  pulmonary  affections  of  childhood  are 
more  often  double  than  those  of  adolescence.  Again,  the  diag- 
nosis of  the  diseases  of  the  lung  in  children  requires  some  knowl- 
edge of  the  disorders  to  which  they  are  peculiarly  liable,  and, 
above  all,  great  care  and.  patience.  Yet,  no  matter  what  trouble 
be  taken,  the  information  gained  will  amply  repay  for  it. 

Among  some  of  the  peculiarities  of  the  respiratory  function, 
before  the  age  of  puberty,  may  be  mentioned  the  greater  frequency 
of  breathing.  Infants  between  two  months  and  two  years  breathe 
irregularly,  and  about  thirty-five  times  in  a  minute.  Between 
the  ages  of  two  and  six  years  the  average  number  of  respirations 
in  the  same  space  of  time  is  twenty-three.  The  breathing  is  also 
of  a  different  type  from  that  of  the  adult :  it  is  abdominal,  and 
can  be  more  readily  counted  by  noting  the  rising  and  sinking  of 


252 


MEDICAL    DIAGNOSIS. 


the  abdomen  than  by  watching  the  slight  movements  of  the 
chest. 

Of  the  methods  of  physical  exploration,  auscultation  is  in  chil- 
dren the  most  applicable.  It  is  far  more  so  than  percussion,  and 
is  to  be  practised  first,  since  percussion  causes  the  child  to  cry. 
The  voice  as  well  as  the  breathing  may  be  advantageously  listened 
to ;  and  although  the  fretful  patient  will  not  or  cannot  speak,  it 
can  and  does  cry.  From  the  cry,  when  studied  with  the  ear 
applied  to  the  thoracic  walls,  we  may  obtain  the  same  indications 
as  from  the  vocal  resonance.  The  back  of  the  lungs  should  be 
invariably  examined.  It  is  there  that  the  mischief  is  mostly 
seated.  Fortunately,  also,  this  investigation  does  not  occasion  the 
same  fear  or  struggling  on  the  part  of  the  little  sufferer:  hence  it 
is  better  not  to  place  the  ear  to  the  anterior  portion  of  the  chest 
until  the  posterior  has  been  listened  to.  The  position,  too,  in 
which  the  child  is  auscultated  should  vary  with  its  age.  Very 
young  children  may  be  examined  either  in  a  lying  or  sitting  pos- 
ture on  the  lap  of  their  nurses,  or  may  be  held  in  the  arms  of  an 
attendant,  who  is  directed  to  present  the  different  parts  of  the 
thorax  successively  to  the  ear  of  the  physician. 

Before  proceeding  to  the  discussion  of  the  symptoms  of  pul- 
monary diseases  and  of  the  diseases  themselves,  let  us  group  the 
latter  according  to  their  anatomical  seat. 


Diseases  of  the  Lungs  and  their  Coverings. 


Bronchial  Tubes. 


Ling-Tissue. 


Inflammation,  or 
Bronchitis ; 


Acute 


<  Of  large-sized  tubes. 
\  Of  capillary  tubes. 


f  Ordinary  chronic 
Chronic.  J      ^tarrhal  form. 


j  Putrid  bronchitis. 
<■  Fibrinous  bronchitis. 


Dilatation ; 
Narrowing ; 
Diseases  of  bronchial  glands  ; 
[  Spasm  of  muscular  fibres, or  asthma. 

r  Congestion  ; 

Hemorrhages ; 

Apoplexy  ; 

(Edema ; 

Collapse  ; 

Hypertrophy ; 

Inflammation,  or  pneumonia,  in  varied  forms  ; 
I  Induration ; 


Lung-Tissue.  —  Con- 
tinued  


Pleura. 


Pleura  and  Lung..  < 


DISEASES    OF    THE    LUNGS.  253 

f  Phthisis  of  different  kinds  ; 

Ahscess ; 

Cirrhosis ; 

Gangrene ; 

Emphysema ; 

Tuhercle,  chronic  and  acute  ; 

Cancer ; 

Deposits,  such  as  syphilitic,  typhoid,  melanic,  etc.  ; 
[  Parasites. 
'  Inflammation,  or  pleurisy  ; 

Empyema  ; 

Hydrothorax  ; 

Hemothorax ; 

Tuberculosis  ; 

Malignant  growths. 

Pneumothorax ; 

Perforations  and  fistulous  openings. 

Pleurodynia ; 
Walls  oe  Chest....  -j   Intercostal  neuralgia  ; 

Abscesses,  etc. 


The  Principal  Symptoms  of  Diseases  of  the  Lungs. 

After  having  in  general  terras  described  the  physical  signs; 
after  having  alluded  to  the  methods  pursued  to  ascertain  the  ex- 
istence of  pulmonary  affections, — it  is  necessary  to  inquire  into 
the  more  prominent  symptoms  they  occasion.  At  the  same  time, 
several  of  the  disorders  which  are  mainly  recognized  by  these 
symptoms,  and  the  physical  signs  of  which  are  comparatively 
unimportant,  will  be  dwelt  upon. 

Yet  of  the  symptoms  about  to  be  mentioned,  not  one  belongs 
exclusively  to  pulmonary  diseases.  We  have  met  with  some  of 
them  in  studying  laryngeal  complaints ;  we  shall  meet  with  them 
again  in  examining  the  affections  of  the  heart.  And  in  investi- 
gating them  here  we  shall  not  view  them  simply  with  reference  to 
morbid  states  of  the  lungs,  but  shall  indicate  their  general  relations 
to  diseased  conditions,  even  at  the  risk  of  discussing  what  might 
in  part  be  more  appropriately  discussed  elsewhere. 

The  symptoms  which  it  is  proposed  more  specially  to  sift  are 
dyspnoea,  cough,  and  haemoptysis. 

Dyspnoea. — Dyspnoea  means  difficulty  of  breathing.  It  is 
accompanied  mostly  by  a  sense  of  uneasiness  and  suffocation,  and 


254  MEDICAL    DIAGNOSIS. 

by  increased  frequency  of  the  respiratory  acts.  But,  strictly 
speaking,  it  is  not  correct  to  apply  the  term  dyspnoea  to  mere 
increased  frequency  of  breathing,  for  accelerated  respiration  and 
difficult  respiration  do  not  of  necessity  go  hand  in  hand.  The 
breathing  maybe  slower  than  natural,  yet  laborious;  it  maybe 
quick,  and  not  impeded.  Pneumonia  furnishes  often  an  example 
of  this. 

Dyspnoea  depends  upon  various  causes.  Feeble  persons  are 
sometimes  troubled  with  it  after  the  slightest  exertion.  It  may 
be  temporarily  produced  by  any  bodily  or  mental  excitement.  It 
is  observed  when  the  play  of  the  diaphragm  is  interfered  with, 
and  the  lung  cramped  in  its  expansion.  This  is  its  cause  in 
ascites,  in  abdominal  tumors,  and  in  pregnancy.  It  may  occur  in 
perverted  innervation,  as  in  hysteria,  or  in  connection  with  cere- 
bral affections,  from  a  want  of  power  in  the  respiratory  muscles, 
or  it  may  be  due  to  morbid  conditions  of  the  blood,  as  in  anaemia, 
scurvy,  and  pyaemia.  It  is,  however,  most  frequently  met  with 
as  a  prominent  symptom  of  the  disorders  of  the  larynx  and 
trachea,  or  of  the  heart,  and  in  the  various  diseases  of  the  lung 
and  pleura,  whether  idiopathic  or  secondary.  Being  common  to 
so  many  morbid  states,  it  is  not  diagnostic  of  any. 

Dyspnoea  is  usually  aggravated  by  position.  When  the  patient 
lies  on  his  back,  the  respiration  becomes  more  difficult.  The  form 
of  dyspnoea  in  which  the  sufferer  is  obliged  to  remain  in  the  erect 
posture  in  order  to  breathe,  is  termed  arrthopnem.  This  is  mostly 
witnessed  in  hydrothorax,  in  oedema  of  the  lung,  and  in  affections 
of  the  mitral  or  tricuspid  valves.  In  phthisis  there  is  rarely 
marked  dyspnoea.  In  capillary  bronchitis  the  trouble  in  respiring 
is  very  great ;  so,  too,  is  it  in  pneumothorax,  in  emphysema,  and 
in  pleurisy,  if  the  lung  be  extensively  compressed. 

Dyspnoea  may  come  on  in  paroxysms,  and  constitute  the  only, 
or  certainly  the  main,  symptom  of  disease.  This  is  the  case  in 
asthma. 

Asthma. — Asthma  consists  in  a  spasmodic  narrowing  of  the 
bronchial  tubes,  caused  by  a  contraction  of  their  circular  muscu- 
lar fibres.  Its  chief  symptom  is  great  distress  in  breathing,  oc- 
curring in  paroxysms,  and  attended  with  wheezing.  These  spasms 
may  be  preceded  by  a  feeling  of  suffocation,  or  they  may  come  on 
suddenly.     The  patient  wakes  up  out  of  his  sleep,  finds  himself 


DISEASES    OF    THE    LUNGS.  255 

wheezing  and  with  a  fit  of  the  disease  fully  on  him.  He  con- 
tinues to  respire  with  great  difficulty,  sits  upright  in  bed,  or 
walks  about  the  room  gasping  for  breath.  His  look  is  wild  and 
anxious,  the  face  pale,  the  skin  cold,  and  the  color  of  the  lips 
shows  that  the  blood  is  not  properly  aerated.  In  spite  of  the 
struggle  to  get  air  into  the  lungs,  the  chest  moves  but  little;  and 
when  the  ear  is  placed  on  it,  no  vesicular  murmur  is  heard, — 
simply  the  same  loud  wheezing  which  is  perceptible  to  the  by- 
standers; or  sonorous  and  sibilant  rales  are  detected,  due  to  the 
narrowing  of  the  bronchial  tubes,  and  disappearing  with  the 
spasm.  These  dry  rales  are  chiefly  expiratory,  and  the  lungs  are 
very  full  of  air,  and  displace,  by  several  intercostal  spaces,  the 
diaphragm  downwards.  At  the  end  commonly  of  some  hours 
the  fit  passes  off  with  copious  expectoration,  and  as  suddenly  as 
it  came.  But  it  may  last  for  days,  ameliorating  in  the  daytime, 
exacerbating  at  night,  and  only  ceasing  gradually. 

The  exciting  causes  of  these  bronchial  spasms  are  various.  In 
some  persons  there  is  no  apparent  reason  for  the  attack ;  in  others 
it  is  brought  on  by  the  inhalation  of  irritating  fumes  or  of  dis- 
agreeable vapors.  In  some  it  is  preceded  by  digestive  troubles, 
or  by  inflammation  of  the  bronchial  mucous  membrane;  in  others, 
again,  an  interruption  to  the  free  circulation  of  blood  in  the  lung, 
or  a  disturbance  in  the  sexual  organs  or  in  the  urinary  secre- 
tions, seems  to  occasion  it.  It  is  not  unusual  to  find,  on  closely 
questioning  patients,  that  for  some  time  prior  to  the  asthmatic 
paroxysm  they  have  passed  a  dark-colored,  heavy  urine. 

Now,  whatever  be  the  exciting  agent  that  calls  the  bronchial 
spasm  into  existence,  the  symptoms  of  the  attack  of  asthma  are 
the  result  of  that  spasm.  Yet  asthma  is  not  often  a  purely 
nervous  disease.  The  seizure  itself  is  the  expression  of  perverted 
nervous  action ;  but  there  are  generally  permanent  conditions 
present,  such  as  disease  of  the  brain  or  medulla  oblongata,  of 
the  heart,  or  of  the  lungs,  which  act  as  constantly  predisposing 
causes  to  these  seizures,  and  lead  to  attacks  either  by  direct  irri- 
tation of  the  pneumogastric  nerves  or  through  the  medium  of  the 
reflex  system.  Emphysema  especially  is  a  fruitful  source  of 
spasmodic  asthma. 

The  detection  of  the  causes  inducing  an  asthmatic  fit  may  be  at 
times  very  difficult ;  but  the  diagnosis  of  the  fit  itself  is  not  so. 


256  MEDICAL    DIAGNOSIS. 

No  disease  of  the  lungs  or  bronchial  tubes  is  likely  to  be  mistaken 
for  it,  because  no  disease  of  either  gives  rise  to  the  same  symp- 
toms. The  dyspnoea  of  pleurisy  or  bronchitis  is  not  paroxysmal, 
nor  is  it  attended  with  wheezing.  Some  of  the  affections  of  the 
larynx  and  trachea  bear  a  nearer  resemblance ;  yet  they,  too, 
announce  themselves  by  different  symptoms.  Asthma  may  be 
distinguished  from  croup  by  the  entire  absence  of  fever,  and  by 
its  lacking  the  peculiar  hoarse  voice  and  cough  which  appertain 
to  both  forms  of  this  malady.  The  age  of  the  patient  is  also 
very  different:  asthma  is  as  rare  in  a  child  as  croup  is  in  an 
adult.  (Edema  and  spasm  of  the  glottis  differ  from  asthma  by 
the  much  more  markedly  paroxysmal  nature  of  the  difficulty  of 
breathing,  by  the  shorter  duration  of  the  seizures,  and  by  the 
absence  of  the  loud  and  continued  wheezing.  The  sensations  of 
the  sufferer,  further,  indicate  correctly  the  seat  of  the  obstruction. 
And  so  they  are  apt  to  do  in  some  of  the  paralyses  of  the  vocal 
apparatus,  where  noisy  dyspnoea  happens,  and  is  aggravated  in 
paroxysms.  Further,  we  are  aided  here  by  the  aphonia,  by  the 
inspiratory  character  of  the  stridulous  breathing,  by  the  absence 
of  chest  rales,  and  by  the  obvious  lesion  seen  in  the  laryngeal 
mirror.  A  large  goitre  pressing  on  the  trachea  may  give  rise  to 
dyspnoea  and  to  a  noisy  sound  in  breathing ;  but  the  cause  of 
both  is  easily  traced  to  the  tumor  in  the  neck. 

The  most  deceptive  condition  is  when  the  glands  of  the  neck 
enlarge  suddenly  and  press  on  the  trachea.  I  had,  some  time 
since,  a  young  man  under  my  care  for  acute  bronchitis.  He 
was  progressing  favorably,  when  one  day  he  presented  himself, 
breathing  with  great  difficulty,  and  each  respiration  attended 
with  a  noise  like  the  wheeze  of  asthma.  It  is  very  probable 
that  I  should  have  been  deceived,  and  should  have  regarded  him 
as  having  been  attacked  with  asthma,  had  I  not,  in  looking  at 
his  neck,  detected  the  group  of  enlarged  glands.  Such  cases  are 
extremely  rare,  and  belong  to  the  curiosities  of  medical  practice. 

Marked  dyspnoea  may  be  occasioned  by  the  pressure  of  an 
aneurismal  tumor,  or  by  an  organic  disease  of  the  heart.  But  it 
is  hardly  necessary  to  enter  here  into  a  detailed  description  of  the 
distinctive  character  of  either  of  these  forms  of  troubled  breathing. 
The  stridor  and  the  persistent  difficulty  of  respiration  in  the  first, 
aggravated  though  it  may  become  in  paroxysms,  and  the  constant 


DISEASES    OF    THE    LTJXGS.  257 

want  of  breath  in  the  second,  are  not  likely  to  be  mistaken  for 
the  wheezing  and  the  paroxysmal  dyspnoea  of  asthma.  True 
asthmatic  seizures  may  both  produce  and  be  produced  by  a  dis- 
ease of  the  heart.  But  what  is  called  "  cardiac  asthma"  is  not 
always  a  spasm  of  the  bronchial  tubes :  it  is  usually  only  a  tem- 
porary increase  of  the  dyspnoea,  dependent  upon  a  decided  ob- 
struction to  the  circulation  in  the  lungs,  and  not  accompanied  by 
wheezing. 

There  is  a  peculiar  form  of  difficulty  of  breathing  connected 
with  a  loss  of  power  in  the  diaphragm.  The  patient,  when  the 
disorder  is  fully  developed,  cannot  make  even  the  slightest  effort 
without  his  being  seized  with  a  feeling  of  suffocation  and  his  res- 
piration being  greatly  accelerated.  He  cannot  take  a  long  breath, 
and  often  his  voice  is  much  enfeebled.  But  the  most  significant 
sign  of  paralysis  of  the  chief  respiratory  muscle  is,  that  during 
inspiration  the  epigastrium  and  the  hypochondria  are  depressed, 
while  the  chest  dilates ;  and  the  converse  takes  place  during  ex- 
piration. If  there  be  merely  a  lessened  power  of  the  diaphragm, 
these  phenomena  are  observed  only  during  forced  breathing ;  a 
paralysis  of  one-half  of  the  muscle  occasions  them  on  one  side 
alone.  Duchenne  adds  another  important  diagnostic  test  by 
which  we  may  distinguish  a  paralyzed  state  of  the  diaphragm, 
namely,  that  if  the  phrenic  nerve  be  galvanized,  the  diaphragm 
acts  again  with  proper  strength,  and,  during  inspiration,  the 
abdomen  rises  simultaneously  with  the  thoracic  walls.  To  dis- 
criminate the  cause  of  the  impaired  or  lost  muscular  force, — 
whether  this  be  due  to  a  lesion  of  the  nervous  system,  to  in- 
flammation of  the  muscle  or  of  the  adjacent  textures,  whether 
produced  by  rheumatism  or  by  lead  poisoning,  or  originating  in 
progressive  muscular  atrophy, — we  have  to  rely  chiefly  upon  the 
history  of  the  case.  In  rheumatism  of  the  diaphragm,  an  absence 
of  the  vesicular  murmur  over  the  lower  portions  of  the  chest ;  res- 
piration effected  by  the  upper  ribs  exclusively;  tense,  hard  ab- 
dominal walls ;  want  of  power  to  strain  so  as  to  aid  the  bladder 
or  intestines  in  expelling  their  contents,  with  darting,  stabbing 
pain  from  the  spine  to  the  margin  of  the  ribs  on  each  effort  to 
inspire, — have  been  particularly  noticed.*     In  fatty  degeneration 


*  Chapman,  Boston  Medical  and  Surgical  Journal,  July,  1864. 

17 


258  MEDICAL    DIAGNOSIS. 

of  the  diaphragm,  which  often  coexists  with  a  fatty  heart,  we  find, 
in  its  last  stage,  great  distress  and  difficulty  of  breathing,  and 
death  may  rapidly  follow  the  embarrassed  respiration.* 

Another  form  of  dyspnoea  is  the  so-called  Cheyne-Stokes  respi- 
ration. It  consists  in  inspirations  at  first  short,  then  deeper  and 
more  and  more  labored,  until  the  paroxysm  is  at  its  height;  then 
becoming  shorter,  and  more  and  more  shallow,  until  the  breathing 
is  suspended.  The  pause  lasts  from  one-quarter  of  a  minute  to  a 
minute,  when  the  respiration  begins  again  in  the  same  manner, 
first  faint,  then  a  little  stronger,  then  still  stronger,  then  again 
subsiding  in  a  descending  scale,  to  end  in  the  same  stand-still. 
This  kind  of  breathing  is  a  very  bad  sign.  It  is  apt  to  happen 
when  from  some  cause  the  supply  of  arterial  blood  is  cut  off  from 
the  brain  or  respiratory  centre  in  the  medulla.  It  is  rare  in  dis- 
eases of  the  lungs,  much  more  common  in  fatty  heart,  in  disease 
of  the  aorta,  in  tubercular  meningitis,  in  affections  compressing 
the  medulla  oblongata,  and  in  uraemia. 

Cough. — Cough  is  a  spasmodic  effort,  consisting  in  a  sudden 
and  violent  expiration,  and  having  usually  for  its  object  the 
expulsion  of  some  annoying  substance  from  the  air-passages.  But 
it  may  be  purely  nervous,  and  unconnected  with  the  presence  of 
any  irritating  matter  in  the  respiratory  organs.  There  are  several 
kinds  of  cough :  according  to  the  amount  of  expectoration  which 
follows  the  act,  a  cough  is  dry  or  moist ;  according  to  its  origin, 
it  is  laryngeal,  tracheal,  bronchial,  sympathetic,  etc. 

A  dry  cough  is  indicative  of  irritation.  This  is  often  seated  in 
the  larynx  and  the  trachea,  or  in  their  vicinity,  or  in  the  bronchi, 
or  in  the  lung  itself.  An  elongated  uvula,  and  many  of  the  dis- 
eases of  the  larynx  or  the  pharynx,  give  rise  to  a  dry  cough  :  it 
happens,  too,  in  pleurisy  and  in  the  earlier  stages  of  phthisis.  In 
disorders  of  the  larynx  and  trachea  the  cough  is  attended  with 
a  peculiar  shrill  noise,  or  a  hoarse  sound.  But  the  irritation 
may  not  be  situated  at  all  in  the  respiratory  system.  Affections 
of  the  liver,  stomach,  intestine,  uterus,  or  brain,  will  occasion 
an  obstinate  dry  cough.  It  is  also  produced  by  dentition,  by 
the  presence  of  worms  in  the  intestinal  canal,  and  by  diseases  of 
the  organs  of  circulation.     Again,  it    may  be   strictly  nervous. 

*  Callender,  London  Lancet,  Jan.  1867. 


DISEASES    OF    THE    LUNGS.  259 

The  brazen  cough  of  hysteria  is  dry  ;  indeed,  nearly  all  sympa- 
thetic coughs  possess  a  dry  character. 

A  moist  cough  may  succeed  to  a  dry  cough.  The  moist  cough 
is  rarely  associated  with  any  diseases  but  those  of  the  respiratory 
apparatus.  It  depends,  for  the  most  part,  on  the  presence  of 
fluid  in  the  bronchial  tubes  or  the  lung-structure.  It  attends 
bronchitis  with  free  secretion,  oedema  of  the  lung,  the  more 
advanced  stages  of  all  the  forms  of  phthisis,  and  pneumonia 
when  the  exudation  is  breaking  up.  It  is  generally  accompanied 
by  a  free  expectoration,  which  varies  in  appearance  and  amount 
with  the  morbid  state  causing  it. 

Cough  is  frequently  preceded  by  a  sensation  of  tickling  in  the 
larynx,  to  which  the  patient  is  apt  to  refer  his  whole  trouble.  It 
is  much  affected  by  position.  Lying  down  often  increases  its 
intensity.  Sometimes  a  cough  occurs  in  severe  paroxysms.  In 
various  laryngeal  affections,  in  abscess  of  the  lung,  in  consump- 
tion, and  in  bronchial  phthisis,  such  fits  of  coughing  are  observed. 
But  in  no  complaint  are  they  so  constant  as  in  hooping-cough. 

Hooping-cough. — This  is  essentially  a  disease  of  childhood,  and 
the  result  of  an  epidemic  influence,  or  of  contagion.  The  peculiar 
spasmodic  cough  succeeds  to  a  catarrh  of  more  than  a  week's  dura- 
tion. During  the  paroxysms  the  eyes  fill  with  tears,  the  child's 
face  is  injected  and  anxious,  and  its  whole  appearance  shows  how 
it  is  suffering  for  want  of  breath.  The  air  in  the  lungs  is  expelled 
by  a  series  of  abrupt  spasmodic  expirations,  when  a  long-drawn 
inspiration,  attended  with  a  hoop,  temporarily  puts  a  stop  to  what 
appears  to  be  threatening  suffocation.  The  rest  is,  however,  short. 
The  cough  recommences,  and  is  again  followed  by  the  loud  hoop- 
ing inspiration.  It  continues  in  this  manner  until,  after  a  copious 
expectoration  of  stringy  mucus,  or  after  vomiting,  the  paroxysm 
ceases,  and  a  more  lengthened  calm  ensues.  These  fits  of  cough- 
ing repeat  themselves  at  varied  intervals  during  the  twenty-four 
hours.  They  are  very  frequent  at  night.  Yet  the  child's  health 
remains  good,  in  spite  of  the  violence  of  the  attacks  and  the 
length  of  time  they  are  spread  over.  The  spasmodic  cough  lasts 
for  weeks ;  the  hoop  then  ceases,  the  cough  loses  its  ringing  sound, 
and  gradually  leaves  entirely.  It  is  only  in  comparatively  rare 
instances  that  it  persists,  and  is  followed  by  the  development  of 
tubercles  in  the  lungs;  just  as  it  is  only  in  exceptional  instances, 


260  MEDICAL    DIAGNOSIS. 

or  in  certain  epidemics,  that  bleeding  from  the  nose  or  convulsions 
happen  during  the  violent  coughing.  In  about  one-half  the  cases 
the  cough  is  violent  enough  to  produce  ulceration  of  or  around 
the  frsenum  linguae,  from  the  force  with  which  the  tongue  is  pro- 
pelled against  the  teeth.  Frequently  the  ulcer  is  covered  with  a 
grayish  exudation;  it  is  never  noticed  before  the  paroxysmal  stage 
is  well  established. 

An  affection  of  so  long  duration,  marked  by  such  a  peculiar 
sign  as  a  hoop,  is  easy  of  diagnosis.  Yet  there  are  certain  con- 
ditions with  which  occasionally  it  may  be  confounded.  In  its 
first  stage,  before  the  characteristic  cough  sets  in,  it  may  be  mis- 
taken for  catarrhal  bronchitis.  There  is,  indeed,  at  this  period, 
no  means  of  distinguishing  between  the  two  disorders,  except  by 
taking  into  account  whether  or  not  hooping-cough  be  prevalent 
as  an  epidemic;  for  it  is  only  seldom  that  the  cough  possesses 
from  the  onset  a  decided  ring.  And  bronchitis  is  in  fact  the 
most  frequent  complication,  or,  to  state  it  more  accurately,  almost 
an  essential  element,  of  the  malady.  It  is  usually  present  in  a 
mild  form  at  the  onset;  it  outlasts  the  paroxysmal  stage.  At  the 
height  of  this,  a  severe  attack  of  acute  bronchitis  or  of  broncho- 
pneumonia may  mask  the  special  traits  of  pertussis.  Yet  when- 
ever these  are  detected  we  know  that  the  complaint  before  us 
is  not  pure  catarrhal  bronchitis.  It  is  true  that  occasionally  acute 
bronchitis  may  exhibit  paroxysms  of  spasmodic  cough.  But  the 
want  of  the  nervous  element  in  the  disease,  the  absence  of  the 
hoop  and  of  vomiting,  the  dyspnoea  between  the  paroxysms,  the 
decided  fever,  the  presence  of  many  rales  indicating  abundant 
secretions  in  the  lung,  the  greater  violence  and  the  shorter  duration 
of  the  disorder,  do  not  permit  us  to  be  long  in  doubt. 

A  disease  less  easy  to  discriminate  from  hooping-cough  is  tuber- 
culization of  the  bronchial  glands,  or  bronchial  phthisis.  It,  too, 
produces  a  ringing  paroxysmal  cough.  It,  too,  occurs  in  chil- 
dren. There  is,  however,  this  difference :  the  enlarged  bronchial 
glands  are  apt  to  press  on  the  surrounding  parts.  This  becomes 
manifest  by  the  engorgement  of  the  veins  of  the  neck,  by  the 
lividity  and  puffiness  of  the  skin,  by  the  trouble  in  breathing  or 
in  swallowing.  The  character  of  the  voice,  also,  may  change; 
and  yet,  as  at  times  happens  in  hooping-cough,  there  may  be  no 
abnormal  physical  signs  in  the  chest.     But  often  there  is  dulness 


DISEASES    OF    THE    LUNGS.  261 

on  percussion  between  the  scapulae,  where  the  swollen  bronchial 
glands  lie,  and  impaired  respiration  in  portions  of  the  lung.  The 
symptoms  are  those  of  pulmonary  phthisis,  with  which  the  disease, 
indeed,  may  be  associated  :  there  are  emaciation  and  the  same  loss 
of  strength,  the  same  sweating  at  night,  the  same  hectic  fever, 
the  same  tendency  to  diarrhoea.  At  times  the  affection  of  the 
glands  induces  a  chronic  pneumonia  with  cheesy  degeneration.* 
Now,  when  we  compare  these  phenomena  with  those  presented  by 
hooping-cough,  we  miss  the  hoop,  the  vomiting  accompanying  the 
fits  of  coughing,  the  ulceration  or  tearing  of  the  frsenum  of  the 
tongue, — a  symptom  usual,  at  least,  in  decided  cases, — the  epidemic 
or  contagious  origin,  and  the  distinct  periods,  first  of  catarrh,  then 
of  spasmodic  cough,  then  of  gradual  decline.  We  see,  on  the  con- 
trary, an  aifection  of  more  gradual  and  uniform  progress,  which 
often  proves  its  existence  by  special  signs,  among  which  a  venous 
hum,  heard  when  the  stethoscope  is  placed  upon  the  upper  bone 
of  the  sternum  while  the  child  bends  back  the  head,  has  been 
particularly  noticed.f 

When  emaciation,  hectic  fever,  and  marked  cough  are  met  with 
in  the  last  stage  of  hooping-cough,  it  is  always  highly  probable 
that  this  has  been  followed  by  a  tubercular  deposit.  It  is  not 
likely  that  such  cases  will  be  mistaken  for  those  instances  of  pul- 
monary consumption  in  which  violent  paroxysms  of  coughing 
occur.  The  age,  the  origin,  the  history,  are  different.  Equally 
dissimilar  are  the  history  and  the  symptoms  in  other  spasmodic 
coughs,  such  as  that  of  hysteria,  or  of  some  laryngeal  affections. 

The  Sputa. — The  consistency  of  the  expectoration  varies  very 
much.  When  it  is  viscid  and  tough  it  contains  a  large  amount 
of  mucus  or  muco-pus,  and  depends  generally  upon  inflammation 
or  a  high  degree  of  irritation  of  the  bronchial  membrane  or  of  the 
lung  parenchyma.  When  it  is  less  tenacious  it  has  far  less  mucus, 
and  a  preponderance  of  pus.  When  fluid  and  full  of  air  it  floats ; 
when  dense  and  without  air  it  sinks.     Fluid  sputum  forms  a 

*  Samuel  Gee,  St.  Bartholomew's  Hosp.  Kep.,  1877. 

f  Eustace  Smith,  London  Lancet,  Aug.  1875.  Eefer,  for  cases  of  diseases 
of  the  bronchial  glands,  to  J.  C.  G.  Tice,  Medico-Chirurg.  Transact.,  vol. 
xxvi. ;  P.  H.  Green,  ibid.,  vol.  xxvii. ;  Barthez  and  Killiet,  Maladies  des 
Enfants,  tome  iii.;  and  De  Mussy,  Gaz.  des  Hop.,  No.  67,  1868,  where  also 
instances  of  the  disease  in  adults  are  analyzed. 


262  MEDICAL    DIAGNOSIS. 

homogeneous  mass ;  dense  sputum  assumes  a  round  or  irregularly 
round  shape.  When  these  purulent  masses  float  in  a  thinner  ex- 
pectoration, we  have  the  coin-shaped  or  nummular  sputum,  so 
common  in  instances  of  pulmonary  cavities. 

The  quantity  of  the  expectoration  varies  greatly  in  different 
diseases  of  the  lungs.  In  the  most  acute  stages  or  in  spreading 
inflammations  it  is  usually  small,  and  increases  as  the  difficulty 
lessens.  In  bronchial  dilatation,  in  pulmonary  abscesses,  es- 
pecially when  they  burst,  and  in  the  voiding  of  a  collection  of 
pus  in  the  pleura  through  the  bronchial  tubes,  the  amount  dis- 
charged is  very  large. 

The  color  of  the  sputum  depends  a  great  deal  on  its  constituents. 
When  mucous,  it  is  white ;  when  muco-purulent,  yellowish  or  yel- 
lowish-green ;  when  purulent,  generally  greenish  or  of  a  yellow- 
crreen.  It  is  also  tinged  by  bile,  by  pigment,  and  by  blood,  and 
a  colored  sputum  forms  thus  the  fourth  of  the  chief  forms  of 
expectoration. 

Sputum  consists  chiefly  of  water,  albumen,  and  mucin.  Mi- 
nutely examined  it  exhibits  pavement  and  columnar  epithelium, 
pus-corpuscles,  blood-globules,  various  forms  of  crystals,  such  as 
the  slender  needles  of  the  fatty  acids,  and  peculiar  spindle-shaped 
bodies,  fibrinous  coagula,  fungous  growths,  and  elastic  fibres. 
The  latter  and  the  fatty  acids  are  encountered  in  diseases  in- 
volving destruction  of  the  lung-tissue.  The  fungous  growths  are 
most  common  in  the  sputum  from  cavities,  in  putrid  bronchitis, 
and  in  gangrene.  Fibrinous  masses  are  particularly  associated 
with  acute  pneumonia  and  with  plastic  bronchitis. 

Haemoptysis. — Sputa  are  streaked  with  blood  in  bronchitis, 
intimately  admixed  with  blood  in  pneumonia;  yet  we  do  not  call 
this  haemoptysis.  It  is  only  when  a  certain  quantity  of  pure 
blood  is  expectorated  that  the  complaint  is  regarded  as  haemoptysis, 
or  hemorrhage  from  the  lungs.  Now,  a  pulmonary  hemorrhage 
may  be  an  idiopathic  affection;  but  it  is  not  often  so.  It  is  mostly 
symptomatic  of  a  grave  disease  of  the  lungs  or  heart,  and  usually 
of  tubercular  consumption.  It  is  at  times,  although  rarely,  a  dis- 
charge which  takes  the  place  of  a  suppressed  flow  of  blood  from 
another  part  of  the  body.  Some  females  have  these  vicarious 
hemorrhages  from  the  lungs  at  their  menstrual  periods. 

It  is  a  matter  of  dispute  among  pathologists  where  the  blood 


DISEASES    OF    THE    LUNGS.  263 

springs  from.  It  would  seem,  in  some  cases,  to  proceed  from  the 
capillaries  and  finer  arterial  branches  of  the  bronchial  mucous 
membrane  and  lung-tissue;  in  others,  from  larger  vessels  that 
have  been  laid  open.  But  what  interests  us  mainly  as  diagnos- 
ticians is  to  ascertain  whether  it  flows  from  the  lung  at  allj  and, 
subsequently,  why  this  organ  is  so  disordered.  Now,  when  called 
to  a  person  who  has  been  spitting  blood,  we  have  first  to  solve  the 
question,  Where  does  the  blood  come  from  ?  It  may  issue  from 
the  nose  or  mouth ;  from  the  trachea ;  from  the  oesophagus  or 
stomach  ;  it  may  stream  from  an  aneurism  which  has  burst  into 
the  air-passages ;  or  it  may  be  that  the  lung  is  bleeding. 

When  in  epistaxis  the  blood,  instead  of  flowing  out  of  the  nostrils, 
flows  backward,  it  is  coughed  up.  But  on  the  patient  inclining 
forward,  it  will  issue  from  the  nose.  The  color  of  the  blood  is  not 
florid ;  and  it  can  be  seen  trickling  down  the  pharynx.  Inspection 
is  of  equal  service  when  the  blood  comes  from  any  part  of  the  oral 
cavity;  especially  if  it  proceed  from  the  gums.  Their  swollen 
state,  their  spongy  appearance,  and  the  readiness  with  which  they 
bleed  when  pressed,  point  out  at  once  the  source  of  the  hemorrhage. 

Loss  of  blood  from  the  larynx  and  the  trachea,  or  from  the 
oesophagus,  is  exceedingly  rare ;  and  when  it  does  occur,  it  is  de- 
pendent upon  some  local  lesion,  or  the  presence  of  some  foreign 
substance  which  has  been  swallowed.  By  attention  to  the  history, 
then,  we  can  recognize  the  cause  and  the  seat  of  the  hemorrhage. 
The  blood  itself  furnishes  no  certain  mark  of  distinction. 

When  blood  is  vomited  from  the  stomach,  it  is  preceded  by  a 
feeling  of  weight  and  uneasiness  in  the  epigastric  region,  and 
sometimes  by  decided  nausea.  The  ejected  matter  consists  of 
a  dark  grumous  blood,  thus  altered  by  the  gastric  juice,  and  is 
often  mixed  with  broken-down  food.  Its  dark  color  is  invariable, 
except  where  an  artery  has  been  laid  bare  by  an  ulcer,  in  which 
case  a  sudden  discharge  of  florid  blood  takes  place.  There  is  not 
commonly  more  than  one  act  of  vomiting ;  the  blood  which  re- 
mains in  the  stomach  passes  into  the  intestines,  and  goes  off  with 
the  stools.  Heematemesis  is  attended  with  tenderness  at  the 
epigastrium.  It  is  usually  symptomatic  of  an  organic  affection  of 
the  stomach,  liver,  intestine,  or  spleen ;  it  may,  however,  depend 
upon  the  swallowing  of  irritating  poisons ;  or  happen  in  fevers  or 
in  scurvy,  or  as  a  substitute  for  suppressed  discharges. 


264  MEDICAL    DIAGNOSIS. 

The  blood  which  gushes  out  of  the  mouth  when  an  aneurism, 
opens  into  the  air-passages  is  red  and  arterial.  It  spurts  out  in 
jets,  and  the  patient  rarely  long  survives  the  hemorrhage.  Should 
this  not  prove  quickly  fatal,  we  are  seldom  at  a  loss  to  determine 
the  cause  of  the  bleeding ;  for  the  physical  signs  of  the  aneurismal 
tumor  in  the  chest  assist  us  in  arriving  at  a  correct  understanding 
of  the  case. 

But  when  the  blood  comes  from  the  lungs,  it  presents  characters 
and  is  connected  with  symptoms  totally  different  from  any  of 
those  just  mentioned.  The  bleeding  is  preceded  by  a  sense  of 
weight  and  of  uneasiness  in  the  chest.  The  patient  perceives  a 
saltish  taste  in  the  mouth  and  a  tickling  sensation  in  the  larynx, 
when  suddenly,  and  without  any  effort,  the  mouth  fills  with  blood, 
or  after  a  slight  cough  he  expectorates  a  quantity  of  light-red  and 
frothy  blood.  His  anxiety  becomes  great ;  the  skin  is  covered 
with  a  cold  sweat ;  the  pulse  is  quick  and  full,  and  bounds  under 
the  finger.  He  spits  up  more  blood,  and  this  continues  to  come 
up  at  varying  intervals  and  in  changing  quantities  all  day,  or  for 
several  days,  or  even  for  a  very  much  longer  period.  It  is  at  first 
pure  blood,  or  mixed  with  the  sputum ;  is  red  and  not  coagulated, 
and  frothy,  except  when  the  hemorrhage  is  very  profuse.  But 
after  one  or  two  bleedings,  the  matter  which  is  coughed  up  con- 
tains dark  clots,  being  the  blood  which  has  been  retained  some- 
where in  the  air-passages  since  the  previous  attack.  The  blood  is 
never,  at  the  onset  of  the  hemorrhage,  dark  and  grumous ;  yet  in 
rare  cases  it  has  more  of  a  venous  than  of  an  arterial  hue. 

The  amount  which  is  brought  up  at  one  bleeding  ranges  from 
one  to  two  drachms  to  as  many  pints ;  but  the  quantity  that  comes 
out  of  the  mouth  is  by  no  means  an  index  of  the  quantity  extrava- 
sated.  The  blood  may  be  effused  into  the  pulmonary  structure, 
and  but  little  be  expelled. 

,  After  the  description  above  given,  it  is  not  necessary  to  point 
out  the  marks  of  discrimination  between  blood  ejected  from  the 
lungs  or  from  other  parts.  The  symptoms  are  different ;  the 
blood  itself  is  different.  And  listening  to  the  chest  detects  bub- 
bling sounds  in  the  air-tubes ;  still,  to  find  these  is  not  requisite 
for  the  diagnosis  of  pulmonary  hemorrhage,  and  indeed,  while 
the  bleeding  is  going  on,  the  patient's  welfare  forbids  an  extended 
thoracic  examination.     But  as  soon  as  circumstances  permit,  that 


DISEASES    OF    THE    LUNGS.  265 

examination  becomes  of  immense  value  by  teaching  us  with  what 
morbid  state  the  hemorrhage  is  connected.  Auscultation  alone 
can  determine  whether  the  bleeding  is  symptomatic  of  a  disease  of 
the  heart  or  the  lungs,  or  whether  it  does  not  depend  upon  either. 
It  is,  however,  mostly  owing  to  an  affection  of  the  heart  or  lungs, 
and  is  exceedingly  prone  to  be  repeated. 

Yet  the  lungs  may  bleed  frequently  without  there  being  an 
organic  lesion  within  the  chest  to  account  for  the  hemorrhage.  I 
had,  some  years  ago,  a  patient  under  my  care,  who  had  been  spit- 
ting blood  daily  for  five  years.  Although  enfeebled  by  the  loss 
of  blood,  his  general  health  remained  good.  His  lungs  and  heart 
appeared  to  be  sound.  Another  patient  had  pulmonary  hemor- 
rhages at  varying  intervals  for  eighteen  months.  He  finally  died 
of  exhaustion ;  but  he  never  presented  any  physical  signs  of  tho- 
racic disease.  It  is,  however,  likely  enough  that  latent  tubercle 
existed.  An  examination  of  the  body  was,  unfortunately,  not  per- 
mitted. But  in  the  case  of  a  gentleman  that  I  had  watched  for 
years,  the  repeated  hemorrhages  were  found  at  the  autopsy  to  be 
unconnected  with  disease  of  the  lungs.  He  died  of  an  acute  dis- 
ease complicated  with  pleurisy. 

In  these  instances  the  hemorrhages  recurred  often.  But  we 
meet  with  robust  persons  in  whom  the  loss  of  blood  follows 
active  exercise  or  exertion  and  is  not  apt  to  be  protracted.  In 
such  cases,  of  which  I  have  seen  a  number  in  soldiers  sent  to 
hospitals  after  the  fatigue  of  a  long  march  or  the  excitement  of  a 
battle,  simple  congestion  of  the  lungs  is  probably  the  cause  of  the 
disorder. 

Except  under  the  circumstances  mentioned,  haemoptysis  may  be 
looked  upon  as  a  grave  symptom.  It  is  not  dangerous  as  regards 
its  immediate  termination,  but  dangerous  because  it  is,  for  the 
most  part,  the  index  of  a  serious  malady.  Few  die  as  the  direct 
consequence  of  the  hemorrhage,  but  many  die  of  the  disorder  of 
which  the  hemorrhage  is  the  consequence. 

Diseases  in  which  Clearness  on  Percussion  is  met  with  and 
constitutes  a  Valuable  Sign. 
Some  of  these  ailments  are  acute,  others  chronic;  and  nearly 
all  have  as  their  prominent  symptom  a  cough,  and  are  affections, 
or  follow  affections,  of  the  bronchial  tubes. 


266  MEDICAL    DIAGNOSIS. 

Acute  Bronchitis. — This  is  an  acute  inflammation  of  the 
bronchial  tubes,  which  occurs  idiopathically,  or  happens  as  a 
secondary  complaint  in  the  course  of  fevers,  of  rheumatism,  and 
of  cardiac  disorders.  Let  us  examine  the  manifestations  of  the 
idiopathic  malady. 

Bronchitis  varies  considerably  according  to  the  size  of  the  tubes 
involved.  When  the  smaller  tubes  are  affected,  a  disease  called 
capillary  bronchitis,  or  suffocative  catarrh,  is  established,  the  prog- 
nosis of  which  is  very  grave,  and  the  diagnosis  of  which  presents 
points  for  special  consideration. 

The  forms  of  bronchitis,  dissimilar  as  they  are  clinically,  do  not 
differ  much  in  their  anatomy.  Whatever  portion  of  the  mem- 
brane the  inflammation  attacks,  swells,  becomes  injected  and  re- 
laxed, and  may  undergo  partial  softening.  Its  surface  is  either 
dry,  or  covered  with  cast-off  epithelium,  muco-pus,  and  exudation 
matter,  which,  if  it  collect  in  the  smaller  tubes,  blocks  up  their 
calibre.  In  ordinary  bronchitis,  the  pulmonary  texture  is  undis- 
turbed; likewise  in  capillary  bronchitis,  unless  the  inflammation 
have  here  and  there  run  into  the  lung  parenchyma  and  solidified 
some  of  the  lobules. 

The  symptoms  of  acute  bronchitis  of  the  large  and  middle-sized 
tubes  are,  a  sensation  of  tickling  in  the  throat,  soreness  or  pain 
behind  the  sternum,  a  slight  oppression  in  breathing,  rather  hur- 
ried respiration,  and  a  paroxysmal  cough.  Let  us  add  to  these 
pain  in  the  limbs,  coryza,  and  a  fever  of  moderate  intensity,  and 
we  have  the  main  phenomena  met  with  during  the  onset  and  at 
the  height  of  an  attack  of  ordinary  acute  bronchitis.  The  fits 
of  coughing  in  the  earlier  stages  are  followed  by  a  clear,  frothy 
expectoration,  which,  as  the  cough  becomes  looser  and  less  fa- 
tiguing, changes  from  an  almost  transparent  fluid  to  a  yellowish 
or  greenish  sputum.  This  may  be  uniform  or  streaked  with 
blood  ;  it  may  be  small  in  amount,  or  in  large  quantities.  The 
fever  soon  leaves;  but  long  after  it  has  ceased,  the  patient  still 
has  a  cough  and  expectoration,  both  of  which  only  gradually 
disappear. 

The.  physical  signs  maybe  inferred  from  the  lesions.  As  there 
is  no  condensation  of  pulmonary  tissue,  there  is  no  dulness  on 
percussion,  the  thickening  and  injection  of  the  bronchial  mucous 
membrane  not  being  sufficient  to  modify  materially  the  normal 


DISEASES    OF    THE    LUNGS.  267 

resonance.  But  these  conditions  must  alter  the  respiratory  mur- 
mur. They  bring  out  more  of  the  bronchial  element  of  sound, 
hence  more  expiration  with  the  coarser  inspiration, — in  other 
words,  a  harsh  respiration ;  or  the  swelling  obstructs  the  entrance 
of  air  into  the  air-vesicles,  and  enfeebles  the  vesicular  murmur. 
Again,  new  sounds,  the  rales,  are  produced ;  first  dry,  then 
moist.  This  succession  of  the  rales  is,  however,  not  absolute, 
and  depends,  to  a  great  degree,  on  the  density  of  the  fluid  in  the 
bronchial  tubes.  Dry  rales,  mixed  with  moist,  may  be  perceived 
even  in  the  later  stages  of  acute  bronchitis,  and  long  after  the 
febrile  signs  have  ceased.  In  fact,  the  tenacity  alone  of  the 
exudation  determines  the  nature  of  the  rales,  and  even  somewhat 
their  exact  character ;  for  every  dry  rale  is  not  precisely  like 
every  other  dry  rale,  nor  every  moist  rale  equally  moist.  With 
reference  to  size,  the  sonorous  rales  and  the  large  bubbling  sounds 
prevail  when  the  disorder  attacks  the  larger  tubes.  Sometimes, 
when  the  bronchial  inflammation  is  severe  and  extensive,  we  find 
a  sound  which  seems  to  be  neither  a  dry  nor  a  bubbling  rale,  but 
rather  a  compound  of  both, — a  dry  sound,  yet  not  continuous, 
giving  the  idea  of  being  caused  by  the  breaking  up  of  fluid.  Or, 
there  may  be  a  mixture  of  the  sounds  of  respiration  with  the 
rales,  occasioning  a  peculiar  kind  of  breathing, — one  in  which 
we  can  recognize  neither  a  distinctly  vesicular  nor  a  distinctly 
bronchial  element,  nor  a  well-defined  rale.  All  these  states  are 
dependent  upon  the  amount,  and,  above  all,  upon  the  condition, 
of  the  exudation  in  the  bronchial  tubes.  But  they  indicate 
nothing  beyond  the  fact  that  there  is  an  exudation  present  which 
is  very  large  in  quantity  and  tenacious  in  character.  When  the 
sounds  are  of  the  indeterminate  nature  just  alluded  to,  the  vi- 
brations produced  in  the  tubes  are  apt  to  be  transmitted  to  the 
parietes  of  the  chest,  occasioning  with  each  respiration  a  marked 
fremitus. 

The  diagnosis,  then,  of  acute  bronchitis  is  determined  by  the 
cough,  the  fever,  the  expectoration,  and  the  signs  of  clearness  on 
percussion,  diffused  rales,  or  harsh  respiration.  From  all  those 
diseases  of  the  lung  which  result  in  the  consolidation  of  the  pul- 
monary tissue,  such  as  pneumonia  and  tuberculosis,  we  distinguish 
bronchitis  by  the  absence  of  dulness  on  percussion.  Some  cases 
of  acute  consumption,  on  account  of  the  sudden  invasion  of  the 


268  MEDICAL    DIAGNOSIS. 

malady  and  the  general  diffusion  of  the  physical  signs,  are  liable 
to  be  mistaken  for  acute  bronchitis ;  but  the  different  progress  of 
the  disorder  usually  clears  up  all  doubt.  Error  in  diagnosis  is 
more  likely  to  arise  from  the  habit,  when  the  signs  of  bronchitis 
have  been  made  out,  of  not  looking  further  ;  forgetting,  in  the 
attention  to  the  disease  within  the  thorax,  the  various  morbid 
states  which  bronchitis  may  accompany,  and  particularly  its  fre- 
quent association  with  fevers. 

Capillary  Bronchitis. — This  is  a  disease  of  the  aged  and  of 
young  children.  It  begins  with  an  acute  inflammation  of  the 
larger  bronchi;  or  the  disorder  may  from  the  onset  affect  the 
smaller  tubes.  In  either  case,  signs  of  obstructed  circulation  soon 
manifest  themselves;  there  is  lividity  of  the  lips  and  cheeks,  with 
hurried  breathing,  a  rapid  pulse,  an  anxious  countenance,  great 
restlessness,  moderate  fever  temperature,  and  a  cough,  followed 
by  viscid  expectoration.  As  the  malady  advances,  the  color  of 
the  skin  and  the  mucous  membranes  shows  more  and  more  the 
want  of  properly  aerated  blood ;  the  sputa  cease  with  the  failing- 
strength  ;  and  in  old  persons  delirium  and  coma,  in  young  chil- 
dren convulsions,  mark  the  closing  struggle. 

The  physical  signs  are  those  of  ordinary  bronchitis,  but  modi- 
fied by  the  seat  of  the  malady.  High-pitched  whistling  sounds, 
accompanied  or  superseded  by  very  fine  moist  rales,  denote  the 
smaller  size  of  the  tubes  involved.  The  resonance  on  percussion 
is  clear,  or  very  slightly  different  from  that  of  health.  When 
materially  duller,  it  indicates  that  the  pulmonary  tissue  itself 
shares  in  the  inflammation,  or  that  it  has  been  exhausted  of  its 
air  and  has  collapsed. 

The  parts  of  the  lung  which  the  physical  signs  prove  to  bear 
the  brunt  of  the  disease,  are  the  lower  lobes.  In  the  upper  there 
may  be  large  rales  and  some  fine  ones ;  but  it  is  low  down  and  at 
the  posterior  portion  of  the  chest  that  the  fine  sounds  are  most 
abundant.  Yet  when  the  inflammation  is  extensive,  and  the 
accumulation  of  secretions  and  morbid  products  great,  quantities 
of  small  rales  are  heard  at  every  part  of  the  chest. 

From  this  description  of  capillary  bronchitis,  it  will  be  ap- 
parent that  it  differs  from  ordinary  acute  bronchitis  in  the  greater 
tendency  to  prostration  and  to  suffocation,  in  the  signs  of  im- 
perfect aeration  of  the  blood,  and  in  the  fineness  of  'the  rales. 


DISEASES    OF    THE    LUNGS.  269 

Like  the  more  usual  kind  of  acute  bronchial  inflammation, 
capillary  bronchitis  is  liable  to  be  mistaken  for  acute  lobar  pneu- 
monia and  for  phthisis.  And  in  the  majority  of  cases  the  same 
rules  serve  for  its  discrimination  ;  the  absence  of  percussion  dul- 
ness  and  the  diffusion  of  the  morbid  sounds  are  here  again  of 
the  utmost  value.  The  rapidity  of  the  attack  and  the  signs  of 
suffocation  might  mislead  into  the  supposition  of  the  existence 
of  oedema  of  the  glottis,  of  laryngitis,  or  of  croup ;  errors  in  diag- 
nosis which  the  detection  of  fine  rales,  by  the  application  of  the 
ear  to  the  chest,  will  prevent. 

Capillary  bronchitis  is  apt  to  be  confounded  with  lobular  or 
broncho-pneumonia, — a  form  of  inflammation  of  the  lung  occur- 
ring mainly  in  children,  which  follows  catarrhal  bronchitis  or  pul- 
monary collapse.  The  disease  is  most  commonly  observed  after 
measles,  hooping-cough,  influenza,  or  diphtheria,  and  is  apt  to 
be  attended  by  cerebral  symptoms  and  high  fever.  As  it  is 
limited  to  the  lobules,  it  yields  but  imperfect  signs  of  consoli- 
dation. The  bronchial  breathing  is  rarely  very  marked;  the 
minute  rale  indicative  of  exudation  into  the  air-cells  is  not  usually 
perceived,  or  can  scarcely  be  distinguished  from  the  small  bub- 
bling sounds  of  capillary  bronchitis ;  and,  from  the  usual  associa- 
tion of  the  malady  in  question  with  inflammation  of  the  fine 
bronchial  tubes,  it  is  in  individual  cases  often  difficult,  nay,  it  is 
impossible,  to  say  whether  portions  of  the  lung-tissue  are  con- 
solidated, or  whether  the  inflammation  is  limited  to  the  tubes. 
Theoretically  speaking,  broncho-pneumonia,  or  "  catarrhal  pneu- 
monia," as  it  is  now  very  generally  called,  may  be  distinguished 
from  bronchitis  by  the  dulness  on  percussion ;  practically,  this 
aids  but  little.  Dulness  on  percussion  is  in  children  difficult 
to  elicit ;  and,  again,  a  dulness  may  be  temporarily  produced  in 
capillary  bronchitis  by  collapse  of  the  pulmonary  tissue.  There 
are,  therefore,  no  absolute  signs  of  difference.  Still,  we  may 
suspect  that  the  inflammation  has  infiltrated  the  lobules,  if  the 
breathing  be  very  rapid,  the  fever  severe,  or  the  temperature, 
which  is  rarely  above  102°  in  the  preceding  bronchitis  of  the 
finer  tubes,  rise  suddenly  by  several  degrees;  if  the  cough  lessen 
as  the  pneumonia  develops,  if  laryngeal  symptoms  arise,  and  if, 
in  addition  to  rales,  not  very  diffused,  spots  of  dulness,  which  do 
not  change  their  seat,  and  do  not  disappear  under  respiratory  per- 


270  MEDICAL    DIAGNOSIS. 

cussion,  be  discerned,  and  pleurisy  without  effusion  appear  as  a 
complication.  On  the  other  hand,  when  there  are  most  marked 
signs  of  deficient  aeration  of  blood;  when  the  symptoms  point 
more  to  prostration  than  to  activity  of  febrile  action ;  when  the 
child  seems  to  suffocate  from  want  of  power  to  expectorate ;  when 
a  multitude  of  fine  dry  and  moist  sounds  are  heard  at  every  part 
of  the  chest,  and  little  or  no  corresponding  impairment  of  the 
natural  resonance  on  percussion  is  detected, — we  know  that  the 
capillary  bronchi  are  extensively  filled  with  pus  and  morbid 
secretions,  and  that  a  disease  even  graver  than  broncho-pneumo- 
nia, that  true  suffocative  catarrh  is  threatening  life.  Capillary 
bronchitis  in  its  marked  form  is  a  rapid  disease ;  catarrhal  pneu- 
monia runs  a  much  slower  course,  generally  lasting  weeks. 

Chronic  Bronchitis. — The  symptoms  and  signs  of  chronic 
bronchitis  are  not  very  different  from  those  of  the  ordinary  form 
of  acute  bronchitis.  The  duration  of  the  complaint  and  the  ab- 
sence of  marked  fever  are  the  chief  distinguishing  elements.  Yet 
the  cough,  although  on  the  whole  chronic,  is  far  from  being  con- 
stant. It  may  disappear  almost  altogether,  and  then  reappear 
with  more  than  its  previous  severity;  and  this  state  of  things  may 
go  on  for  years,  undue  exposure  and  change  of  season  aggravating 
the  disorder. 

The  sputa  vary,  even  more  than  in  acute  bronchitis,  in  tenacity 
and  quantity.  There  may  be  merely  a  small  quantity  of  yellowish 
matter  expectorated  in  the  morning,  or  an  almost  continued  flow 
from  the  bronchial  tubes, — bronchorrhcea.  The  physical  signs 
differ  accordingly.  A  harsh  or  feeble  respiration,  and  few  or 
many,  either  dry  or  moist,  rales  are  present,  in  conformity  with 
the  state  of  the  bronchial  mucous  membrane  and  of  its  secretions. 
The  sound  on  percussion  is  clear.  Excessive  secretions  somewhat 
impair  the  pulmonary  resonance ;  but  only  temporarily ;  for  with 
the  shifting  secretions  shifts  the  slight  dulness. 

One  of  the  most  important  points  in  the  diagnosis  of  chronic 
bronchitis  is  to  attend  to  the  manner  in  which  it  arises.  It  may 
follow  a  seizure  of  ajute  bronchitis,  or  be  the  result  of  recurring 
attacks  of  subacute  character ;  it  may  appear  as  a  primary  affec- 
tion ;  or  it  may  follow  the  exanthemata ;  or,  again,  it  may  compli- 
cate some  previously  existing  disorder,  as  Bright's  disease,  rheu- 
matism, gout,  psoriasis,  or  eczema,  and  be  directly  traceable  to  the 


DISEASES    OF    THE    LUNGS.  271 

constitutional  taints  of  these  maladies ;  and  its  symptoms  will  vary 
and  be  influenced  by  those  of  the  general  malady  to  which  it  is 
subordinate. 

In  the  ordinary  idiopathic  malady  the  general  health,  as  a  rule, 
suffers  but  little.  In  some  instances,  however,  emaciation  takes 
place,  and  the  disease  simulates  phthisis.  This  is  particularly 
the  case  in  the  bronchial  affections  among  knife-grinders  and 
coal-miners,  also  in  those  of  granite-masons,  of  sandpaper-makers, 
of  flax-dressers,  and  of  potters.*  The  resemblance  becomes  still 
greater  when  superadded  bronchial  dilatation  and  fibroid  indura- 
tion of  the  lung  produce  physical  signs  like  those  of  pulmonary 
consumption.  Ordinarily  the  chronicity  of  the  cough,  the  occa- 
sional subacute  exacerbations,  the  small  amount  of  constitutional 
disturbance,  the  post-sternal  pain,  the  diffusion  of  the  signs  dis- 
cerned on  auscultation,  and  the  clearness  on  percussion,  constitute 
a  group  of  phenomena  which  does  not  permit  an  error. 

A  chronic  catarrhal  inflammation  of  the  mucous  membrane  of 
the  nose  may  be  mistaken  for  chronic  bronchitis,  with  which,  in- 
deed, it  may  coexist.  But  when  occurring  uncombined,  there  are 
no  rales  in  the  chest,  or  altered  breathing-sounds  indicative  of 
disorder  there,  though  there  may  be  a  cough,  from  the  throat 
being  also  affected.  The  secretion,  too,  from  the  nose  is  very 
copious  and  of  muco-purulent  character,  the  upper  part  of  the 
nose  looks  somewhat  flattened,  and  the  sense  of  smell  is  impaired, 
— not  one  of  which  signs  is  met  with  in  chronic  bronchitis. 

It  seems  almost  unnecessary  to  speak  of  the  differential  diag- 
nosis between  chronic  bronchitis  and  rose  cold  and  hay  asthma. 
The  coexistence  of  marked  signs  of  irritation  of  the  eyes,  nose, 
and  throat,  the  appearance  of  the  distressing  affections  at  a  par- 
ticular period  of  the  year,  the  fixed  time  in  which  they  run  their 
course,  the  almost  instant  relief  on  leaving  the  regions  where  the 
attack  has  been  brought  on  and  reaching  favorable  localities,  the 
depression  of  the  nervous  system,  and,  on  the  other  hand,  the  less 
decided  signs  of  bronchial  trouble,  clearly  distinguish  the  maladies. 

We  meet  occasionally  with  a  form  of  bronchitis  in  which  the 


*  See  Parson  on  Potters'  Bronchitis,  Edinburgh,  1864 ;  also  a  Lecture  on 
Bronchitis  from  Mechanical  Irritation,  in  Greenhow's  work  on  Chronic 
Bronchitis,  London,  1869;  and  Lebert,  Klinik  der  Brustkrankheiten. 


272  MEDICAL    DIAGNOSIS. 

expectorated  matter  is  solid.  This  plastic  bronchitis  presents  all 
the  usual  signs  and  symptoms  of  bronchial  inflammation.  It 
may  be  chronic,  or  it  may  be  acute.  It  is  most  frequently  chronic, 
with  occa>ional  acute  or  subacute  exacerbations.  The  disease  ex- 
tends in  this  way  over  weeks,  months,  or  even  years,  and  is  apt 
to  end  in  complete  recovery.  But  in  its  acute  form  it  is  a  com- 
plaint of  great  danger,  and  accompanied  by  much  dyspnoea,  and 
has  led  to  death  by  suffocation.*  Males,  as  we  find  by  looking 
at  the  cases  which  Dr.  Peacockf  has  collected,  are  more  often 
attacked  than  females.  The  same  carefully  collated  observations 
show  that  the  disorder  affects  more  commonly  the  upper  than  the 
lower  part  of  the  lungs.  As  regards  the  physical  signs,  Fuller,;}; 
who  has  met  with  a  number  of  well-marked  examples  of  the  com- 
plaint, states  that  there  is  weakness  or  entire  absence  of  breathing 
over  the  affected  portions  of  the  lungs ;  and  that,  from  attending 
collapse,  complete  and  rapidly  developed  dulness  on  percussion 
may  ensue.  But  the  only  absolutely  diagnostic  phenomenon  is 
the  peculiar  membranous  material  expectorated.  In  form  this 
may  be  either  in  thin  shreds,  or  moulded  into  an  accurate  cast 
of  a  bronchial  tube  and  its  ramifications.  The  expectoration  of 
the  firm  bodies  is  sometimes  attended  with  copious  haemoptysis. 

The  little  round  solid  pellets  which  consumptive  patients  or 
even  some  persons  in  good  health  cough  up,  from  time  to  time, 
are  the  result  of  a  plastic  bronchitis  on  a  very  limited  scale. 

Emphysema. — A  distention  of  the  air-cells  is  a  frequent 
sequel  of  chronic  bronchitis.  It  may  happen  in  only  one  lung; 
but  the  air-vesicles  of  both  are  usually  distended.  The  effect  of 
this  is  to  obliterate  some  of  the  capillaries,  and  to  interfere  with  a 
flow  of  blood  through  the  lungs.  From  this  proceed,  to  a  great 
extent,  the  feeling  of  constriction  and  the  dyspnoea,  the  anxious 
look,  the  bluish  lip  of  emphysematous  patients,  and  the  tendency 
the  disease  has  to  produce  dilatation  or  dilated  hypertrophy  of  the 
right  side  of  the  heart. 


*  Andral ;  also  Hilton  Fagge,  Trans,  of  Path.  Soc,  vol.  xvi. ;  Biermer, 
YirchowTs  Handbuch  der  Pathologic  ;  Riegel,  in  Ziemssen's  Cyclopedia  :  and 
Glascow,  Trans,  of  Amer.  Med.  Association,  1879. 

f  Transactions  of  the  Pathological  Society,  veil.  v.  ;  Medical  Times  and 
Gazette,  vol.  ix. ;  also  De  Havilland  Hall,  St.  Barth.  Hosp.  Kep.,  1877. 

|  Diseases  of  the  Chest. 


DISEASES    OF    THE    LUNGS. 


273 


Emphysema  is  essentially  a  chronic  malady ;  but  in  its  course 
subacute  attacks  of  bronchitis  occur  which  much  augment  the 
difficulty  of  respiration.  The  trouble  in  breathing  is,  indeed,  the 
most  prominent  of  the  symptoms.  It  is  not  so  much  the  diffi- 
culty of  getting  air  into  the  lung,  as  it  is  of  getting  it  out,  which 
annoys  the  patient.  He  breathes  as  if  he  had  no  object  but  that 
of  forcing  the  air  out  of  the  pulmonary  tissue.  And  this  task  is 
often  aggravated  by  spasmodic  narrowing  of  the  bronchial  tubes. 
In  fact,  nothing  is  more  common  than  to  meet  with  the  loud 
wheezing  of  asthma  in  those  whose  air-cells  are  permanently 
dilated. 

The  physical  signs  of  emphysema  are  easily  deducible  from 
the  pathological  conditions.      The  distention  of  the  lung-tissue 

Fig.  23. 


r, 


1 1 


A>  - 


Appearance  of  the  chest  in  a  patient  suffering  from  a  high  degree  of  emphysema. 
The  heart  is  displaced.  The  other  physical  signs  are  extreme  percussion  clearness; 
a  feeble,  hardly  audible  inspiration ;  a  very  prolonged  expiration. 

explains  the  great  prominence  and  fulness  of  the  chest,  and  the 
displacement  of  the  liver  or  heart.     The  ringing  clearness  on  per- 

18 


274  MEDICAL    DIAGNOSIS. 

cussion — at  times,  in  fact,  almost  tympanitic  in  its  character — and 
the  increased  resistance  to  the  finger  have  the  same  cause.  Nor 
is  it  difficult  to  understand  how  the  loss  of  elasticity  in  the  dilated 
air-cells  will  give  rise  to  an  unchanged  note  on  respiratory  percus- 
sion, to  prolonged  expiration,  and  to  a  feeble  inspiratory  murmur. 
If  bronchitis  coexist,  the  signs  on  auscultation  are  necessarily 
somewhat  altered.  The  respiration  is  harsh,  or  intermixed  with 
dry  and  moist  rales.  The  former  especially  assume  great  promi- 
nence, and  are  heard  as  sonorous,  or  still  oftener  as  sibilant,  rales, 
during  the  prolonged  and  labored  act  of  expiration.  When  the 
emphysema  is  partial,  all  these  signs  are  limited;  when  more 
general,  they  are  diffused. 

If  the  upper  lobe  of  the  right  lung  or  the  lower  lobe  of  the 
left,  which,  as  Louis*  tells  us,  are  the  parts  most  frequently 
affected,  be  emphysematous,  the  visible  local  bulging  might  mis- 
lead into  the  idea  of  the  prominence  being  due  to  an  aneurismal 
tumor,  or  to  the  presence  of  fluid  in  the  pleural  cavity.  Any 
doubt  will,  however,  be  dispelled  by  a  careful  examination  of  the 
chest.  The  dulness  over  an  aneurismal  tumor,  its  pulsation,  and 
its  sounds,  are  different  from  the  exaggerated  clearness  on  percus- 
sion and  the  changed  respiratory  murmur  of  an  emphysematous 
lung.  Pleuritic  effusions  produce  a  bulging  at  the  lower  part  of 
the  thorax.  But  although  there  may  be  a  very  clear,  or  rather  a 
tympanitic,  sound  above  the  fluid,  the  absolute  dulness  over  it 
shows  that  the  prominence  of  the  chest  is  not  caused  by  distended 
air-vesicles.  When  the  emphysema  is  extended  and  general, 
there  is  little  or  no  action  of  the  diaphragm,  and  the  complaint 
gives  rise  to  displacement  of  the  liver  or  heart ;  and  this  circum- 
stance, taken  in  connection  with  the  dilatation  of  the  chest  and  the 
dyspnoea,  brings  the  malady  into  a  category  of  affections  which 
will  be  examined  hereafter.  When  considering  this  group,  we 
shall  return  to  emphysema,  and  point  out  its  distinguishing  marks 
from  the  disease  for  which  it  is  most  likely  to  be  mistaken, — 
pneumothorax.  Let  us  only  add  here  that,  in  its  general  forms, 
emphysema  is  apt  to  be  associated  with  marked  signs  of  cachexia. 

A  few  words  on  a  variety  of  the  complaint  closely  correspond- 
ing to  what  surgeons  term  emphysema  : 

*  Memoires  de  la  Soc.  Med.  d'Observation,  tome  i. 


DISEASES    OF    THE    LUNGS.  275 

An  effusion  of  air  may  take  place  into  the  areolar  tissue  uniting 
the  lobules.  There  are  no  physical  signs  peculiar  to  this  inter- 
lobular emphysema ;  they  are  exactly  the  same  as  those  furnished 
by  dilatation  of  the  air-cells,  except  that  a  dry  friction  sound  and 
a  large,  dry  crackling  (both  of  which  occur  occasionally  in  vesic- 
ular emphysema)  are  much  more  common.  Xor  are  there  any 
general  circumstances  specially  indicative  of  the  disease,  save  its 
suddenness,  and  the  external  emphysema  which  follows.  The 
latter  is  detected  under  the  jaw,  or  at  the  base  of  the  neck,  and 
yields  a  peculiar  crepitation.  Yet  the  extravasation  of  air  into 
the  areolar  tissue  of  the  neck  is  not  a  constant  attendant  on  the 
extravasation  of  air  in  the  lung.  Besides,  the  possibility  of  a 
crepitating  swelling  in  the  neck  being  due  to  a  rupture  of  the 
bronchial  tube  or  of  the  larynx  must  be  borne  in  mind. 

The  rupture  of  the  air-cells  which  gives  rise  to  interlobular 
emphysema  is  brought  about  by  any  severe  effort,  by  violent 
coughing,  by  laughing,  or  by  the  throes  of  parturition.  It  has 
also  been  known  to  happen  in  the  course  of  pneumonia  or  of  pul- 
monary hemorrhage,  and  to  have  caused  sudden  death.  Its  most 
frequent  association,  however,  is  with  hooping-cough. 

In  all  of  the  disorders  which  have  just  been  treated  of,  the* 
resonance  on  percussion  has  been  dwelt  upon  as  a  most  valuable 
sign.  Before  proceeding  to  consider  the  diseases  in  which  dulness 
is  encountered,,a  few  words  may  here  find  their  place  on  a  morbid 
condition  in  which  clearness  rapidly  gives  way  to  dulness,  and 
dulness  changes  quickly  back  into  clearness.  As,  moreover,  the 
complaint  to  which  I  allude — collapse  of  the  Iwig — bears  a  close 
connection  to  bronchitis  and  emphysema,  and  has  been  made  to 
play  an  important  part  in  the  explanation  of  some  of  their  symp- 
toms and  complications,  its  consideration  is  at  this  time  fitting. 

In  noticing  that  dulness  on  percussion  sometimes  appears  in 
the  course  of  a  case  of  capillary  bronchitis,  it  was  remarked  that 
this  does  not  of  necessity  show  that  the  inflammation  has  extended 
to  the  lobules;  it  may  be  owing  to  the  air  in  the  lung  being  ex- 
hausted, and  the  pulmonary  tissue  collapsed.  Collapse  of  the 
lane  is  thus  a  return  of  the  organ  to  a  condition  akin  to  its  fcetal 
state,  and  takes  place  throughout  a  large  portion  of  the  lungs, — 
diffused  collapse, — or  it  is  lobular.    Formerly  the  lobular  collapse 


276  MEDICAL    DIAGNOSIS. 

was  invariably  mistaken  for  lobular  pneumonia.  Yet  the  aspect 
of  the  lung  in  many  instances  of  lobular  pneumonia  had  attracted 
the  attention  of  pathologists  long  before  Legendre  and  Bailly 
inflated  the  supposed  hepatized  lobules  and  demonstrated  their 
essential  difference  from  the  recognized  features  of  hepatization 
by  restoring  them  absolutely  to  their  normal  condition.  This 
discovery  enhanced  the  importance  of  bronchitis,  and  lessened 
that  of  lobular  pneumonia;  for  it  was  found  that  an  accumulation 
in  the  bronchial  tubes  was  the  most  frequent  exciting  cause  of 
that  condensation  of  the  pulmonary  tissue  which  had  previously 
been  regarded  as  a  sure  indication  of  an  inflammation. 

These  accumulations  occasion  collapse  by  shutting  up  the  tube 
through  which  the  air  reaches  the  air-vesicles.  No  air  can  enter; 
the  residual  air  is  gradually  exhausted,  and  the  disordered  portion 
of  lung;  is  reduced  to  a  state  as  if  it  had  never  breathed.  But 
although  in  the  majority  of  instances  this  condition  of  things  is 
brought  about  by  catarrhal  secretions  in  the  bronchial  tubes  which 
cannot  be  expectorated,  it  would  be  a  mistake  to  suppose  that 
these  are  always  present.  Any  want  of  power  to  fill  the  cells  of 
the  lung  with  air  may  lead  to  their  collapsing.  In  some  of  the 
typhoid  forms  of  acute  and  chronic  diseases,  in  the  pulmonary 
congestions  of  the  aged  and  enfeebled,  and  in  those  occurring  just 
prior  to  death,  large  portions  of  the  lung-tissue  may  collapse 
simply  from  inability  to  breathe  with  sufficient  force. 

Such  is  a  sketch  of  collapse  of  the  lung  from  a  pathological 
point  of  view.  When  we  come  to  inquire  whether  the  diagnostic 
signs  of  this  condition  are  so  clearly  defined  that  we  can  always 
make  out  a  collapsed  state  of  the  pulmonary  tissue,  we  have  to 
admit  that  our  knowledge  of  the  pathological  phenomena  as  yet 
exceeds  our  power  to  recognize  them  in  the  living.  The  physical 
signs  are  uot  satisfactory ;  the  symptoms  vary  with  the  conditions 
producing  the  disease.  There  is  dulness  as  in  the  other  forms  of 
condensation,  as  in  pneumonia,  as  in  pleurisy.  Neither  voice  nor 
respiration  is  characteristic.  The  most  usual  physical  sign  is  dul- 
ness on  percussion,  with  an  absence  of  all  respiration,  or  with  a 
blowing  sound,  which  is  faint  and  not  so  distinct  as  in  pneumonia. 
The  dulness  is,  on  the  whole,  not  great,  may  be  changed  during 
respiratory  percussion,  and  in  cases  dependent  upon  inspissated 
mucus  may  disappear  suddenly  when  the  obstructing  cause  is  re- 


DISEASES    OF    THE    LUNGS.  277 

moved.  Yet  collapse  of  the  lung  is  at  times  a  state  of  long  dura- 
tion. Great  stress  is  laid  by  some  on  the  signs  of  emphysema 
which  surround  the  dulness  of  the  condensed  tissue;  and  should 
a  pneumonic  process  affect  the  collapsed  portion,  the  dulness  is 
stationary. 

After  collapse  the  breathing  becomes  very  difficult.  The  patient 
makes  intense  efforts  at  inspiration.  Rees  tells  us  that,  owing  to 
the  non-expansion  of  the  lung  during  these  efforts,  the  ribs  move 
inward  and  recede,  instead  of  moving  outward  as  in  ordinary 
respiration.  This  sign,  the  suddenly  increased  dyspnoea,  and 
the  appearance  of  dulness  unaccompanied  by  marked  bronchial 
breathing,  are,  in  a  case  of  bronchitis,  the  most  trustworthy  indi- 
cations that  collapse  of  the  lung-tissue  has  taken  place.  Yet  where 
the  collapsed  lobules  are  small  and  scattered  through  the  lung, 
these  signs  are  not  all  present,  and  the  diagnosis  is  uncertain. 
The  dulness  is  wanting;  and  the  peculiarity  in  inspiration  may 
not  be  observed. 

When  collapse  affects  a  large  portion  of  lung,  it  much  resembles 
lobar  pneumonia  and  pleurisy,  from  both  of  which,  however,  it 
may  often  be  distinguished  by  the  phenomena  indicated,  and,  still 
more  positively,  by  the  history  and  the  absence  of  that  group  of 
symptoms  and  physical  signs  which  characterizes  inflammation  of 
the  lung  or  pleura.  How  nearly  it  resembles  catarrhal  pneumo- 
nia has  already  been  stated.  The  diminution  in  volume  of  por- 
tions of  the  chest,  the  shifting  character  of  the  physical  signs,  the 
speedy  re-entrance  of  air  into  parts  that  had  shown  signs  of  con- 
densation, are  the  only  trustworthy  points  in  diagnosis. 

Diseases  in  which  Dulness  on  Percussion  occurs. 

The  diseases  of  the  lungs  in  which  dulness  on  percussion  is  met 
with  are  all  those  in  which  compression  or  consolidation  of  the 
pulmonary  tissue  takes  place.  Especially  do  we  find  dulness,  and 
the  physical  signs  which  accompany  it,  in  the  phthises,  in  pneu- 
monia, and  in  pleurisy. 

Phthisis. — Phthisis  presents  itself  in  a  chronic  and  in  an 
acute  form.  The  chronic  variety  is  by  far  the  most  frequent.  It 
is  essentially  "  the  consumption/'  which  is  such  a  scourge  to  the 
human  race.  In  by  far  the  greatest  number  of  instances  this  con- 
sumption is  linked  to  tubercular  disease.     And  although  we  now 


278  MEDICAL    DIAGNOSIS. 

with  considerable  certainty  recognize  other  forms  of  consumption  ; 
and  it  is  becoming  customary,  following  the  German  pathologists, 
strictly  to  divide  phthisis,  according  to  its  origin,  into  a  tubercular 
and  a  non-tubercular  form,  the  latter  of  which  again  has  as  its 
chief  kind  the  inflammatory  variety, — for  which  it  is  claimed  that 
it  is  the  most  prominent, — yet,  believing,  as  I  do,  that  this  is  much 
the  less  common,  I  shall  retain  phthisis  as  implying  tubercular 
consumption.  I  shall  admit  the  term  as  having  a  generic  mean- 
ing, but,  unless  otherwise  specified,  shall  use  it  as  implying  the 
most  frequent  of  lung  destructions, — from  tubercular  disease.* 

Beginning  usually  with  a  short  and  insidious  cough,  with  a  feel- 
ing of  lassitude,  and  a  decline  in  general  health  ;  attended  at  times 
from  its  onset  with  a  pain  in  the  affected  lung  and  a  somewhat 
quickened  circulation ;  or  giving  the  first  indications  of  its  exist- 
ence by  the  occurrence  of  a  hemorrhage ;  or  developing  itself  after 
severe  bodily  or  mental  fatigue ;  or  traceable  to  some  neglected 
cold, — the  disease  becomes  fully  established,  with  symptoms  which 
hardly  need  a  detailed  description.  The  harassing  cough  by  day 
and  by  night;  the  impaired  appetite  and  disturbed  digestion  ;  the 
loss  of  blood  from  the  lungs;  the  steadily  augmenting  debility; 
the  short  breathing;  the  exhausting  night-sweats;  the  hectic 
fever;  the  deceptive  blush  which  this  imparts  to  the  cheek; 
the  increased  lustre  of  the  eye;  the  singular  hopefulness;  the 
temporary  improvements;  the  relapses;  and  the  greater  vividness 
of  the  imagination,  so  strongly  contrasting  with  the  waning 
frame, — are  phenomena  with  which  sad  experience  has  made  not 
only  every  physician,  but  many  a  fireside,  familiar. 

The  most  constant  of  all  these  symptoms  are  the  hemorrhage, 
the  cough,  and  the  emaciation.  The  cough  is  at  first  dry,  and 
followed  by  a  frothy  expectoration.  As  the  disease  advances,  the 
sputa  thicken.  They  become  greenish  in  color,  streaked  with 
yellow,  and  "nummular,"  consisting  of  large  greenish  masses  of 
a  rounded  form,  or  sometimes  rounded  yet  with  jagged  edges, 
which  masses  do  not  sink  in  the  cup  containing  them,  but  float 
imperfectly  in  a  thin  serum.  This  expectoration  is,  however,  by 
no  means  pathognomonic  of  the  malady.     Cases  of  tubercular 


*  See  a  paper  of  mine,  "On  some  Points  in  the  Pathology  of  Tubercle," 
Phila.  Med.  Times,  June  19,  1880. 


DISEASES    OP    THE    LUNGS.  279 

phthisis  occur  without  it;  and,  on  the  other  hand,  it  is  occa- 
sionally encountered  in  chronic  bronchitis.  In  the  last  stages  of 
consumption  the  sputa  are  often  homogeneous,  and  have  a  dirty- 
grayish,  decidedly  purulent  aspect.  Examined  microscopically, 
they  show  fragments  of  the  structure  of  the  lung,  pus-cells,  exu- 
dation-globules, and  those  peculiar  granular  bodies  which  were  at 
one  time  regarded  as  characteristic  of  tubercle.  Yet  the  only  ap- 
pearances in  the  sputum  at  all  distinctive  are  the  fragments  of  the 
pulmonary  fibrous  tissue.  But,  though  from  their  presence  we 
are  sometimes  enabled  to  suspect  the  existence  of  consumption 
before  the  physical  signs  of  even  its  early  "stages  are  well  defined, 
we  can  never  be  quite  certain  that  the  breakage  of  the  lung-tex- 
ture is  due  to  tubercular  disease.  As  regards  the  so-called  tuber- 
cle-corpuscles, they  are  now  supposed  to  be  shrivelled  pus-cells,  or 
exudation-corpuscles,  and  under  any  circumstance  their  absence 
in  the  expectoration  does  not  disprove  the  possibility  of  the  lungs 
being  filled  with  tubercles.  An  excellent  way  of  finding  the 
lung-tissue  is  by  the  plan  proposed  by  Fenwick,* — to  liquefy  the 
sputum  by  means  of  pure  caustic  soda,  when  any  particles  which 
may  be  contained  in  it  fall  to  the  bottom  of  the  vessel,  and  can  be 
readily  removed  and  placed  under  the  microscope. 

In  another  manner,  too,  has  it  been  proposed  to  make  use  of 
the  sputum  for  diagnostic  purposes.  Taking  as  a  starting-point 
the  discovery  of  Villemin,  that  tubercular  matter  can  be  inoc- 
ulated from  man  to  animals,  Marcetf  suggested  the  inoculation  of 
the  expectoration  of  persons  considered  tubercular.  From  his  ex- 
periments on  guinea-pigs,  he  found  that  these  animals,  when  in- 
oculated with  tubercular  sputum,  die  of  tubercular  disease,  or,  on 
being  killed  thirty  days  after  inoculation,  exhibit  tubercles  in  their 
organs.  More  recent  observations  rendered  it  likely  that  other 
than  tubercular  matter  may,  when  inoculated,  give  rise  to  tuber- 
cular disease;  nay,  it  has  been  stated  that  even  the  inhalation  of 
finely-divided  masses,  as  of  calf's  or  goat's  brain,  will  do  the 
same.  But  it  has  been  denied  that  the  nodules  produced  are  tu- 
bercles, when  other  than  products  derived  from  tubercle  or  from 
cheesy  degeneration  are  used.     The   most  recent  researches  are 

*  Medico-Chirurgical  Transactions,  vol.  xlix. 
f  Ibid.,  vol.  1. 


280  MEDICAL    DIAGNOSIS. 

those  of  Cohnheim,*  who,  inoculating  the  eye  of  rabbits  with  the 
special  products  named,  finds  in  the  chamber  of  the  organ  the 
tubercular  formations  reproduced ;  and  these  then  become  general 
through  the  body.  But  the  whole  matter  is  as  yet  too  uncertain 
to  accord  to  it  much  value  in  diagnosis. 

In  rare  instances,  the  cough  remains  slight  throughout  the 
malady ;  but  generally  it  is  a  very  distressing  feature  of  the 
complaint,  and  is  particularly  worrying  at  night.  Sometimes 
its  violent  paroxysms  bring  on  vomiting. 

Among  the  less  constant  and  distinctive  symptoms  of  pulmonary 
consumption  are  a  troublesome  and  rebellious  diarrhoea,  chronic- 
laryngitis  and  pharyngitis,  and  the  red  line  around  the  border  of 
the  gum.  In  some  persons  this  gingival  line  is  a  mere  streak;  in 
others  it  is  more  than  a  line  in  breadth  ;  in  none  is  it  a  certain  in- 
dication. A  sign  which  has  a  much  more  definite  connection  with 
tubercular  disease  of  the  lungs  is  the  strange  appearance  of  the 
nails.  The  end  of  the  finger  is  somewhat  clubbed;  the  nail  is 
curved,  prominent  in  the  centre,  depressed  at  the  sides,  its  surface 
slightly  cracked,  its  appearance  bluish.  This  peculiar  condition 
of  the  nails  is  tolerably  constant,  and  is  sometimes  met  with  even 
in  the  earlier  stages  of  the  disease.  A  similar  nail  is,  however, 
seen  in  chronic  pleurisy  and  in  diseases  of  the  heart. 

Another  significant  symptom  of  phthisis  is  the  heightened 
temperature  as  ascertained  by  the  thermometer.  Ringer,  t  who 
mainly  drew  attention  to  the  subject,  states,  indeed,  that  the  tem- 
perature may  be  greatly  elevated  for  several  weeks  before  we  find 
physical  signs  indicative  of  the  deposition  of  tubercle,  or  of  an 
undoubted  increase  in  the  already  existing  deposition.  It  is  fur- 
thermore maintained  that  the  rise  in  the  heat  of  the  body  closely 
corresponds  to  the  activity  of  the  deposition  of  tubercle.  If  the 
temperature  be  decidedly  and  permanently  elevated  throughout 
the  day,  there  is  active  deposition ;  if  normal  or  nearly  so  at  one 
period,  though  at  another  it  rise  to  considerable  height,  the  deposi- 
tion is  less  active;  and  it  is  slow  if  the  rise  be  far  less  marked. 
"When  the  animal  heat  is  normal,  the  deposition  in  the  lungs  has 
ceased,  and  the  tubercular  process  is  arrested  or  retrograding. 

*  Quoted  in  London  Lancet,  May,  1880. 
f  On  the  Temperature  of  the  Body. 


DISEASES    OF    THE    LUNGS.  281 

These  statements  are  clinically  of  importance ;  but  I  think,  from 
repeatedly  examining  into  the  matter,  that  they  are  not  to  be 
trusted  absolutely.  They  only  represent  a  general  truth ;  and 
they  do  not  aid  us  much,  for  instance,  in  discriminating  lingering 
lung  complications  in  febrile  states,  or  affections  intercurrent  in 
tubercular  phthisis,  from  a  spread  of  the  disease,  or  certain  forms 
of  persistent  non-tubercular  consolidations. 

The  observations  of  Briinniche*  have  shown  that  the  morning 
temperature  in  phthisis  is  generally  higher  than  the  evening  tem- 
perature. He  found  the  same  rule  in  acute  miliary  tuberculosis. 
Lebert,f  who  does  not  regard  the  thermometer  as  throwing  much 
light  on  the  changes  in  phthisis,  records  that  in  the  last  weeks  or 
last  days  of  the  disease  the  temperature  falls  greatly ;  and  C.  T. 
Williams!  tells  us  that  in  a  large  number  of  chronic  cases  the 
temperature  is  normal  or  subnormal,  sometimes  falling  to  between 
93°  and  94°.  Contrary  to  the  statement  above  made,  he  observed 
a  higher  temperature  in  the  late  afternoon  maintained  until  the 
night.  Tubercle  may,  he  says,  form  and  lung  disorganization 
proceed  without  causing  any  considerable  rise  of  temperature. 
On  the  whole,  therefore,  the  temperature  record  of  tubercular 
phthisis,  certainly  in  its  chronic  state,  is  a  variable  one. 

The  thermometer  has  of  late  been  made  use  of  in  another 
manner  in  the  diagnosis  of  tubercular  consumption.  Peter§  calls 
attention  to  the  advantage  of  local  thermometry.  A  surface  ther- 
mometer is  applied  firmly  in  front  of  the  chest  in  the  second  inter- 
costal space,  and  if  the  temperature  is  higher  there  than  on  the 
other  side,  or  than  normal,  it  is  because  there  are  tubercles  under- 
neath. In  beginning  tuberculosis  the  increased  local  heat  is  in 
proportion  to  the  extent  of  the  lesions.  In  health  the  local  tem- 
perature of  the  chest-walls  is  about  36°  Cent.  (96.8°  Fahr.),  it 
may  rise  to  37°  Cent.,  or  more;  and  in  consumption  with  cheesy 
degeneration  still  higher,  and  may  surpass  the  general  fever  heat 
of  the  body. 

The  symptoms  which  precede  a  fatal  termination  are  various, 


*  Quoted  in  British  and  Foreign  Med.-Chir.  Kev.,  July,  1873. 
f  Archiv  fur  Klin.  Med.,  1872. 

%  The  Doctor;  quoted  in  Half- Yearly  Compendium,  July,  1875. 
§  Clinique  Medicale,  tome  ii.,  1879. 


282  MEDICAL    DIAGNOSIS. 

and  depend  on  the  precise  manner  in  which  the  formidable  malady 
ends.  Patients  may  go  on  failing  for  years;  or  an  intercurrent 
attack  of  acute  tuberculosis,  of  pneumonia,  or  of  inflammation  of 
the  brain  or  of  the  intestinal  tract  may  at  any  time  result  in  death. 

But  at  no  stage  of  the  disease  do  we  derive  as  exact  knowledge 
from  a  study  of  its  symptoms  as  we  do  from  a  study  of  its  phys- 
ical signs.  Before  explaining  these,  it  is  necessary  to  recall  briefly 
some  facts  connected  with  the  general  laws  governing  tubercle ; 
for  I  shall  in  these  descriptions,  as  already  stated,  adhere  to  the 
idea  of  the  tubercular  nature  of  phthisis,  and  use  the  terms  as 
synonyms,  taking  subsequently  special  cognizance  of  the  forms 
lately  so  much  discussed,  especially  the  inflammatory. 

Tubercle  is  an  unorganized  substance,  the  deposits  of  which  are 
at  first  isolated,  then  accumulate.  The  tendency  of  tubercular 
matter  is  to  soften  and  destroy  the  textures  among  which  it  is 
infiltrated.  It  may  undergo,  at  any  period  in  its  course,  a  retro- 
gressive development,  by  shrivelling  up,  or  by  passing  into  a  cal- 
careous state.  When  situated  in  the  lungs,  it  seeks  the  apices  by 
preference ;  it  is  rarely  limited  to  one  lung,  although  one  lung  is 
usually  the  most  diseased,  and  often  at  the  beginning  of  the  malady 
is  alone  affected.  It  is  not  merely  a  local  complaint,  but  stands  in 
connection  with  a  peculiar,  tainted  state  of  the  constitution  :  hence 
the  symptoms  of  phthisis  are  not  solely  the  expressions  of  the 
condition  of  the  lungs. 

These  pathological  facts  are  all  of  the  greatest  importance. 
They  tell  us  where  to  seek  for  the  earliest  indications  of  a  deposit. 
They  explain  to  us  its  signs.  They  teach  us  to  look  further  than 
the  lungs,  and  prepare  us  for  finding  lesions  in  other  organs. 
Thev  point  out  the  path  which  alone  promises  to  lead  to  any  result 
in  treatment. 

In  accordance  with  the  laws  affecting  tubercular  depositions,  we 
have  three  stages  of  phthisis,  which  run,  however,  by  almost  im- 
perceptible degrees  into  one  another.     They  are  : 

1.  Incipient  stage,  or  beginning  deposition; 

2.  More  complete  deposition,  occasioning  consolidation  ; 

3.  Stage  of  softening  and  of  the  formation  of  cavities. 

1.  A  few  scattered  tubercles  do  not  change  the  normal  percus- 
sion resonance ;  nor  do  they  appreciably  alter  the  natural  breath- 
sounds.     But  as  soon  as  the  deposit   is  sufficient  to  impair  the 


DISEASES    OF    THE    LUNGS. 


283 


elasticity  of  the  lung-tissue  or  to  increase  its  density,  a  relative 
loss  of  clearness  on  percussion  on  one  side,  and  modifications 
of  the  vesicular  murmur,  such  as  feeble  or  jerking  inspiration, 
or  a  prolonged  expiration,  may  be  ascertained.  The  dulness  is 
readily  detected  by  percussing  the  patient  with  his  mouth  open 
and  during  a  fixed  expiration,  or  the  diiference  between  the  two 
sides  becomes  very  manifest  during  held  inspiration ;  in  other 
words,  respiratory  percussion  will  aid  us.  To  find  the  dulness  at 
the  upper  part  of  the  chest  posteriorly,  the  position  recommended 

Fig.  24. 


Slight  percussion  dulness. 


Feeble  or  harsh  respira- 
tion  


Prolonged  expiration. 


Exaggerated  respiration.... 


Commencing  infiltration;  masses  of  tubercle  have  accumulated, 
but  the  intervening  lung-tissue  is  still  healthy. 

by  Corson,*  of  crossing  the  arms  and  clasping  the  shoulders,  is 
very  advantageous.  In  a  certain  number  of  cases,  with  the  slight 
dulness  on  percussion  and  changed  breathing  is  associated  a 
blowing  sound  in  the  subclavian  or  in  the  pulmonary  artery.  A 
murmur  is,  indeed,  at  times  present  in  the  pulmonary  artery  long 
before  any  other  physical  indication  of  tubercle  is  discernible. 
All  these  physical  signs  may  be  accompanied  by  rales  of  various 
kinds.     What  makes  them  significant  is,  that  they  occur  at  the 


*  New  York  Journal  of  Medicine,  March,  1859. 


284  MEDICAL    DIAGNOSIS. 

upper  portion  of  the  lung,  whether  anteriorly  or  posteriorly.  If, 
therefore,  any  modification  of  the  vesicular  murmur,  or  any 
adventitious  sound  limited  to  the  apex,  exist;  if  there  be  a  slight 
dulness  on  percussion  above  or  under  the  clavicle,  or  in  the  supra- 
spinous fossa ;  if  this  coincide  with  flattening  of  the  anterior  sur- 
face of  the  chest,  especially  on  one  side,  with  defective  expansion 
of  the  thorax  and  shortness  of  breath,  with  a  cough  and  falling 
off  in  general  health,  the  diagnosis  of  beginning  tubercular  disease 
is  almost  positive. 

2.  As  the  infiltration  advances,  the  signs  become  more  decidedly 
those  of  consolidation.  Greater  dulness  on  percussion  at  the  upper 
portion  of  one  or  of  both  lungs,  scarcely  influenced  by  respiratory 
percussion;  more  resistance  to  the  percussing  finger;  stronger 
vocal  resonance;  a  sinking  in  of  the  side  most  affected,  and  often 
soreness  to  the  touch  over  the  diseased  part;  a  very  harsh  mur- 
mur; or,  when  the  infiltration  surrounds  the  bronchial  tubes,  a 
distinct  blowing  respiration, — are  all  present  in  varying  degree, 
and  all  denote  consolidation.  And  chronic  consolidation  at  the 
apex  has,  in  the  large  majority  of  instances,  but  one  interpreta- 
tion :  phthisis.  In  the  second  stage,  as  well  as  in  the  first,  we 
often  meet  with  superadded  signs  of  bronchitis  which  occasionally 
mask  the  respiratory  sounds,  and  with  friction  sounds  from  local 
pleurisies,  or  with  fine  crackling. 

3.  The  diseased  organ  now  passes  into  a  state  of  softening,  or 
rather  some  portions  of  the  lung  begin  to  soften  while  others 
remain  indurated,  and  in  yet  others  fresh  infiltration  takes  place. 
Moist  crackling  or  persistent  moist  rales  indicate  that  softening 
has  begun.  The  broken-down  material  may  be  expectorated,  and 
the  malady  for  a  time  be  stayed  ;  but  such  is  not  often  the  case. 
The  area  of  the  softened  mass  widens ;  cavities  form  ;  and  in 
addition  to  the  moist  rales,  to  the  physical  phenomena  of  the 
second  stage,  and  to  the  increasing  debility,  night-sweats,  and 
hectic,  the  signs  indicative  of  a  cavity  are  noticed.  What  these 
are,  may  be  learned  from  the  engraving  on  the  following  page. 
Prominent  among  them  are  the  cavernous  voice,  especially  in 
whispering,  and  the  hollow  breathing.  But  the  hollow,  cavernous 
respiration  may  be  caught  only  in  expiration,  or  it  may  be  tem- 
porarily superseded  by  very  large  bubbling  sounds, — gurgling. 
Again,  over  small  or  over  deep-seated  cavities  none  of  these  sounds 


DISEASES    OF    THE    LUNGS. 


285 


may  be  perceived;  and,  in  truth,  even  when  they  exist,  their  lim- 
itation to  a  particular  locality  is  an  element  in  the  diagnosis  of  a 
cavity  almost  as  important  as  their  presence. 

The  results  of  percussion  over  an  excavation  are  not  always  the 
same.     They  depend  much  on  the  thickness  and  the  state  of  the 


Cavernous 
respiration. 

Gurgling. 

Cavernous 
voice. 


Cavities  of  various  sizes. 


walls  of  the  cavity.  If  dense,  percussion  yields  a  dull  sound;  if 
thin,  a  tympanitic,  or  its  varieties,  a  cracked-pot  or  a  metallic  sound. 
If  only  a  certain  amount  of  indurated  tissue  intervene  between  the 
cavity  and  the  surface  of  the  chest,  a  singular  sound,  a  mixture  of 
dull  and  tympanitic,  is  produced.  If  healthy  lung-tissue  form  the 
walls  of  the  excavation,  the  sound  is  clear,  or  nearly  so.  More- 
over, in  all  cases  the  pitch  and,  to  some  extent,  the  character  of  the 
sound  are  changed  by  percussing  over  the  cavity  while  the  mouth 
is  kept  open.  When  it  is  shut,  the  sound  elicited  is  of  lower 
pitch.  On  respiratory  percussion,  the  previously  tympanitic  or 
mixed  sound  becomes  dull.  Another  sign  by  which  we  may  judge 
of  the  existence  of  a  cavity  at  the  upper  part  of  the  lung,  is  the 
extraordinary  clearness  with  which  the  heart-sounds  are  heard  at 
that  point,  or  a  waving  impulse  in  the  second  intercostal  space. 


286  MEDICAL    DIAGNOSIS. 

Such,  then,  are  the  physical  signs  which  indicate  the  varied 
structural  conditions  of  the  lung  in  the  three  stages  of  phthisis. 
With  these  signs  are  associated,  as  symptoms,  cough,  increasing 
quickness  of  breathing,  progressive  debility,  hectic  fever,  digestive 
disorders,  and  emaciation, — symptoms  the  occurrence  and  severity 
of  which  mark  also,  though  not  very  accurately,  the  periods  of 
the  malady.  Irrespective  of  these  three  stages,  some  have  ad- 
mitted a  stage  preceding  the  deposition  of  the  tubercles.  That 
such  a  pretubercular  stage  exists,  is  not  improbable;  that  the 
ability  to  recognize  it  would  be  one  of  the  most  important  and 
valuable  gifts  to  practical  medicine,  is  undoubted  ;  but  whether 
it  be  recognizable,  is  another  matter.  It  does  not  seem  to  me  that 
the  advocates  of  the  possibility  of  detecting  phthisis  at  this  stage 
have  clearly  proved  their  point.  On  the  one  hand,  they  lay  claim 
to  signs,  such  as  diminished  expansion  of  the  chest,  decreased  vital 
capacity,  a  murmur,  feeble  and  remaining  feeble  on  forced  breath- 
ing, haemoptysis,  even  slight  dulness  on  percussion, — a  combina- 
tion which  we  are  accustomed  to  regard  as  evidence  that  tubercle 
already  exists;  on  the  other  hand,  they  assert  that  defects  of  tem- 
perature, lessened  muscular  power,  improper  assimilation,  emacia- 
tion, sore-throat,  and  slight,  dry  cough,  are  prodromic  symptoms. 
Yet  all  of  these  may  be  associated  with  a  temporary  derangement 
of  health,  and  all  of  these  are  far  more  frequently  so  associated 
than  with  threatening  consumption.  And  to  say  that  they  become 
of  value  only  when  coexisting  with  the  physical  signs  alluded  to, 
is  but  to  say  that  they  are  the  clinical  phenomena  which,  thus 
grouped,  we  are  in  the  habit  of  accepting  as  proof  of  the  first 
stage  of  the  disease.  But,  without  entering  further  into  this  ques- 
tion, it  may  be  stated  that  the  deposition  can  generally  be  detected 
at  a  very  early  period  by  careful  explorations  of  the  chest,  and  by 
connecting  the  physical  signs  with  other  sources  of  information, 
such  as  the  symptoms  and  the  history  of  the  case. 

Let  us  now  examine  the  disorders  with  which  phthisis,  in  its 
various  stages,  is  likely  to  be  confounded.  They  are,  to  speak  of 
thoracic  affections  only  : 

Chronic  Bronchitis; 

Chronic  Pneumonic  Consolidation; 

Chronic  Pleurisy; 

Pulmonary  Cancer; 


diseases  of  the  lungs.  287 

Syphilitic  Disease  of  the  Lungs  ; 

Bronchial  Dilatation; 

Pulmonary  Abscess; 

Pulmonary  Gangrene. 

Chronic  Bronchitis. — The  first  stage  of  consumption  is  particu- 
larly prone  to  be  mistaken  for  chronic  bronchitis.  Nor  is  the 
diagnosis  always  easy.  Distinct  dulness  on  percussion  at  the  apex 
is  of  much  aid  in  discrimination,  especially  if  it  be  on  the  left  side. 
On  the  right  side  it  is  of  far  less  value,  unless  marked  alterations 
of  the  vesicular  murmur  correspond  to  it.  When  the  dulness  is 
not  discernible,  we  have  to  depend,  in  our  efforts  at  a  separation  of 
the  two  diseases,  on  the  history  of  the  case,  the  limitation  of  the 
physical  signs  to  the  apex,  and  the  proofs  of  increased  activity  of 
the  surrounding  lung.  Cough  and  expectoration  are  common  to 
both  affections.  But  they  are  associated,  in  chronic  bronchitis, 
with  physical  signs  more  or  less  diffused  through  both  lungs,  and 
unaccompanied  by  much  constitutional  disturbance ;  while  from 
the  onset  of  phthisis  the  falling  off  in  general  health  is  out  of  pro- 
portion to  the  local  lesions.  Yet  until  crackling  or  some  dulness 
on  percussion  is  perceived,  the  diagnosis  remains  uncertain.  These 
indications  of  beginning  consolidation  settle  the  diagnosis  against 
bronchitis.  And  this  view  of  a  case  will  be  strengthened  if  hem- 
orrhage have  occurred,  and  if  the  phenomena  be  present  in  a 
person  born  of  a  family  in  which  consumption  is  hereditary. 

Where  the  deposition  is  at  all  extensive,  an  erroneous  diagnosis 
of  bronchitis  is  with  ordinary  care  impossible,  unless,  as  is  always 
highly  improbable,  phthisis  should  be  complicated  with  emphy- 
sema, or  the  tubercles  be  quiescent  and  so  diffused  as  not  to  im- 
pair the  resonance  on  percussion.  Under  the  latter  circumstances 
especially,  the  occasional  tympanitic  character  of  the  sound  over 
the  seat  of  the  tubercular  deposition  is  liable  to  be  misconstrued 
into  increased  clearness  on  percussion,  and  into  a  disproval  of  the 
existence  of  phthisis.  When  tubercle  and  emphysema  coexist,  the 
percussion  note  may  really  be  pulmonary  and  like  that  of  healthy 
lung.  We  should  then  have  to  judge  of  the  one  disease  following 
the  other  mainly  by  the  respiratory  sound,  which  becomes  much 
feebler;  generally,  too,  the  dyspnoea  is  increased.  Perhaps  the 
thermometer,  as  Ringer  suggests,  by  showing  a  higher  temperature 
than  in  pure  emphysema,  may  assist  us. 


288  MEDICAL    DIAGNOSIS. 

In  the  sta^e  in  which  the  signs  of  consolidation  become  well 
defined,  phthisis  may  be  mistaken  for  any  of  those  conditions 
which  occasion  the  physical  signs  indicative  of  greater  density  of 
the  lung-tissue,  and  which  are  accompanied  by  cough  and  by  loss 
of  flesh.  Such  are  particularly  pneumonic  consolidation,  pleuritic 
effusion,  and  cancerous  deposits. 

Chronic  Pneumonic  Consolidation. — Chronic  pneumonic  con- 
solidation, or,  as  the  affection  is  commonly  called,  chronic  pneu- 
monia, gives  rise  to  many  manifestations  which  simulate  con- 
sumption. These  are  cough,  emaciation,  and  the  local  signs  of 
chronic  condensation, — increased  voice  and  fremitus,  sinking  in  of 
the  chest-wall,  feeble  inspiration  and  prolonged  expiration,  or  a 
fully-developed  bronchial  respiration.  But  in  pneumonic  con- 
solidation the  history  usually  points  to  an  antecedent  acute  affec- 
tion ;  the  health  is  not  so  much  impaired  ;  there  has  been  no 
hemorrhage,  although,  owing  to  intervening  acute  bronchitis,  the 
sputa  at  times  may  have  been  streaked  with  blood  ;  and  thedulness 
on  percussion  and  the  other  physical  signs  of  consolidation  are,  for 
the  most  part,  perceived  over  the  lower  lobe  of  one  lung. 

This  position  of  the  physical  signs  is  of  great  importance.  Yet 
there  are  two  sources  of  fallacy  which  may  arise.  On  the  one 
hand,  tubercles  may,  by  way  of  exception,  be  seated  in  the  lower 
lobe;  on  the  other,  chronic  pneumonic  induration  may  affect  the 
apex.  When  an  infiltration  of  tubercle  takes  place  in  the  lower 
lobe,  its  distinction  from  chronic  pneumonic  condensation  is  very 
difficult.  Our  only  guides  are  the  evideuce  furnished  by  the 
graver  constitutional  symptoms  of  phthisis,  and  attention  to  that 
pathological  law  which  teaches  that  consumption  is  not  met  with 
in  an  advanced, state  in  one  lung  alone;  hence  we  must  watch  care- 
fully the  other  lung.  So  long  as  it  is  not  involved,  there  is  reason 
to  conclude  against  the  tubercular  character  of  the  deposit.  In 
like  manner,  by  ascertaining  the  one-sidedness  of  the  disease,  and 
by  noting  the  want  of  those  serious  symptoms  which  go  hand  in 
hand  with  the  physical  signs  of  tubercular  phthisis,  we  may  deter- 
mine the  real  nature  of  the  case  when  an  inflammation  of  the  upper 
lobe  has  resulted  in  its  persistent  induration.  I  adduce  a  few  in- 
stances, by  way  of  illustration: 

A  gentleman  has  been  under  my  care  for  years,  in  whom,  after 
pulmonary  inflammation,  signs  of  condensation  remained  in  the 


DISEASES    OF    THE    LUNGS.  289 

upper  part  of  the  right  lung.  He  does  not  suffer  at  all,  except 
from  attacks  of  acute  bronchitis,  to  which  he  is  very  liable. 
During  these  he  loses  flesh ;  but  when  they  pass  off  he  rapidly 
regains  it.     He  has  a  chronic  cough,  but  it  is  slight. 

In  another  case,  with  a  similar  history,  I  found  dulness  on  per- 
cussion, prolonged  expiration,  and  a  friction  sound  limited  to  the 
apex  of  the  right  lung.  There  had  been  a  continuous  cough,  but 
very  little  constitutional  disturbance,  and  no  hemorrhage.  The 
abnormal  signs  lasted  for  a  year,  and  then  almost  disappeared 
under  a  succession  of  blisters,  and  the  cough  ceased. 

In  both  cases  the  signs  were  confined  to  the  summit  of  one 
lung.  I  had  some  time  since  under  observation  a  patient  affected 
much  in  the  same  manner,  a  man  seventy-five  years  of  age,  in 
whom  the  dulness  at  the  right  apex  had  for  years  remained  sta- 
tionary. I  might  cite  further  examples;  but  these  are  sufficient 
to  justify  the  conclusions  that  can  be  drawn  from  the  facts  men- 
tioned. 

But  to  return  to  the  points  of  difference  between  chronic  indu- 
ration of  the  lung  and  tubercular  phthisis.  They  may  be  thus 
summed  up :  when  the  signs  of  consolidation,  whether  existing  at 
the  upper  part  of  the  lung  or  not,  are  out  of  proportion  to  the 
general  symptoms,  there  is  reason  to  believe  that  they  are  not  the 
result  of  tubercular  infiltration.  The  non-occurrence  of  hemor- 
rhage would  tend  to  strengthen  such  an  inference.  But  the  most 
important  information  is  drawn  from  watching  whether  the  phys- 
ical signs  undergo  changes  indicative  of  a  deposit  in  the  hitherto 
healthy  portions  of  the  pulmonary  texture.  And  it  must  be  con- 
fessed that  minute  and  accurate  examinations  having  reference 
directly  to  this  point  are  sometimes  the  only  means  through  which 
a  positive  opinion  can  be  reached. 

In  so  close  a  manner,  then,  may  phthisis  be  imitated  by 
chronic  pneumonic  induration ;  a  disease  which  until  lately  has 
been  mostly  ignored,  except  as  a  local  attendant  on  cancerous  or 
tubercular  depositions. 

But  a  great  and  complicating  difficulty  in  the  differential  diag- 
nosis remains  to  be  mentioned.  It  grows  out  of  the  circumstance 
that  tubercular  disease  may  be  developed  in  a  lung  which  is  in  a 
state  of  chronic  induration.  Whatever  the  explanation,  the  fact 
cannot  be  disputed  that  we  find  persons  who  are  without  a  trace 

19 


290  MEDICAL   DIAGNOSIS. 

of  pulmonary  disorder,  seized  with  an  inflammation  of  the  lung, 
which  is  followed  by  persistent  consolidation,  and  in  the  course 
of  time  by  undoubted  phthisis.  Indeed,  many  of  the  reported 
cases  of  tubercle  affecting  primarily  the  lower  lobe  of  the  lung 
are,  in  reality,  cases  of  tubercle  following  chronic  pneumonic 
consolidation.  The  history  is  usually  as  follows.  A  person  in  all 
respects  healthy  is  attacked  with  an  acute  pulmonary  affection. 
He  recovers  from  it,  but  with  a  trifling  cough,  with  a  persistent 
dulness  on  percussion,  and  with  a  feeble  respiration,  heard  over 
one  of  his  lungs.  He  continues  ailing,  yet  is  not  positively  sick, 
when,  without  any  apparent  cause,  after  a  time  varying  from  a 
few  months  to  years,  the  pulse  becomes  frequent,  his  cough  in- 
creases, the  expectoration  augments  greatly  in  quantity  and  be- 
comes decidedly  purulent,  the  temperature  rises,  and  he  emaciates 
rapidly.  Profuse  night-sweats  occur;  and  the  physical  signs, 
which  have  been  stationary  for  a  long  time,  now  begin  to  change. 
The  dulness  extends ;  and,  instead  of  the  enfeebled  respiration,  a 
harsher,  blowing  respiration  is  perceived  over  the  affected  part, 
and  moist  crackling  and  the  signs  of  a  cavity  follow.  Doubt 
may  still  exist  as  to  the  nature  of  the  malady,  but  the  advance 
of  the  disease  clears  up  the  doubt.  True  to  the  laws  of  tubercle, 
a  deposit  takes  place  in  the  lung  previously  sound,  and  not  at  the 
lower  portion,  but  at  its  apex. 

Hemorrhage  may  or  may  not  occur.  In  the  patient  from  whose 
case  the  above  description  is  drawn,  it  did  not  happen ;  and  in 
others,  too,  it  was  wanting.  Its  presence  is,  therefore,  strongly  in 
favor  of  the  fact  that  tubercles  have  been  developed ;  its  absence 
does  not  positively  prove  the  contrary. 

I  leave  these  remarks  as  they  were  originally  written.  Of  kite 
years  a  school  of  pathologists,  with  Niemeyer  at  their  head,  have 
endeavored  to  re-establish  the  old  doctrine  that  consumption  of 
the  lung  and  the  formation  of  cavities  are  most  frequently  the 
result  of  chronic  inflammation.  According  to  this  view,  cases  such 
as  those  just  discussed  belong  to  the  grand  group  of  phthisis  in 
which  the  pneumonic  process  terminates  in  caseous  degeneration 
and  destruction  of  tissue.  This  group,  pneumonic  phthisis,  held 
to  be  the  most  common  form  of  consumption,  presents  somewhat 
different  traits  according  to  the  rapidity  of  its  development.  It 
differs  from  the  true  tuberculous  consumption,  due  to  a  tubercular 


DISEASES    OF    THE    LUNGS.  291 

deposit,  in  this :  the  latter  has  no  precursory  catarrh  or  catarrhal 
pneumonia,  the  marked  fever  and  the  emaciation  are  not  deferred 
until  the  expectoration  becomes  profuse  and  purulent,  the  patient 
wastes,  and  then  begins  to  cough  and  expectorate.  At  first  the 
physical  examination  of  the  chest  may  give  negative  results,  and 
even  at  a  later  period  the  solidification  is  not  so  extensive  as  in  the 
first  form  of  consumption, — that  following  inflammation.  In  this 
there  is  more  uniform  infiltration,  although  the  disease  is  more 
localized;  it  is  slow  in  its  progress;  shows  more  or  less  increased 
temperature,  and  a  tendency,  under  treatment,  toward  contraction 
and  induration  of  the  affected  part  of  the  lung,  which  may  result  in 
a  cure.  Yet  one  of  the  dangers  is  that  it  may  become  tuberculous ; 
though  even  then  the  morbid  process  appearing  at  an  advanced 
stage  of  the  lung-destruction  has  little  to  do  with  the  disorganiza- 
tion of  the  lungs.  How  the  tubercle  arises  is  not  certain,  but  it 
has  some  connection  with  the  cheesy  changes  of  the  products  of 
the  inflammation. 

Now,  the  remarks  made  will  apply  almost  equally  where  the 
original  seizure  was  an  ordinary  croupous  pneumonia,  or  a  catarrhal 
pneumonia.  In  both  wTe  have  the  signs  of  consolidation  remain- 
ing; in  both  the  same  questions  of  diagnosis  may  arise,  as  to 
whether  the  lung  is  undergoing  cheesy  degeneration,  and  as  to  the 
subsequent  formation  of  tubercle.  Yet  there  are  some  points 
which  the  chronic  consolidation  that  attends  a  chronic  catarrhal 
•pneumonia  exhibits,  that  I  shall  here  refer  to.  In  the  first  place, 
the  history  of  a  preceding  acute  catarrhal  attack  is  clear,  or  there 
have  been  a  series  of  attacks,  after  one  of  which  the  lung  was  left 
solid,  and  since  which  the  patient  has  remained  delicate,  prone  to 
take  cold,  and  is  easily  put  out  of  breath.  Now,  he  may  come 
under  our  observation  in  the  midst  of  one  of  these  broncho-pneu- 
monic seizures,  and  we  may  watch  him  for  five  or  six  months  with 
the  signs  of  consolidation  over  portion  of  one  lung,  whether  at  base 
or  apex,  or  with  affected  points,  often  symmetrical,  in  both ;  further, 
there  are  night-sweats,  fever  with  decided  evening  exacerbation, 
diarrhoea.  Gradually  these  urgent  symptoms  yield,  he  gets  about, 
but  a  spot  or  spots  of  consolidation  in  one  or  both  lungs  do  not 
pass  away,  and  the  chronic  catarrhal  pneumonia  may  remain  as 
such  or  terminate  in  caseous  degeneration  in  the  manner  described ; 
may,  in  other  words,  pass  into  pneumonic  phthisis,  which,  I  think, 


292  MEDICAL    DIAGNOSIS. 

means  really  tubercle.*  When  this  happens,  great  variation  be- 
tween morning  and  evening  temperature,  simulating  a  malarial 
fever,  increasing  cough  and  dyspnoea,  marked  sweats,  decided  ema- 
ciation, announce  the  event;  while  the  physical  signs  show  ex- 
tending dulness,  crackling  and  fine  moist  rales,  over  the  affected 
spots,  or  in  parts  not  previously  diseased,  and  ultimately  cavities. 

Chronic  Pleurisy. — A  persistent  cough  attended  with  emaciation 
and  with  dulness  on  percussion  is  common  to  chronic  pleurisy  and 
to  phthisis,  and  is  a  cause  of  many  errors.  But  with  care  such 
errors  may  be  avoided ;  certainly  by  those  who  pay  attention  to 
physical  diagnosis.  The  seat  of  the  dulness  at  the  lower  part  of 
the  thorax;  its  much  more  absolute  character;  the  almost  entire 
cessation  of  all  breath-sound;  the  diminished  or  absent  vibration 
of  the  chest-walls  when  the  patient  speaks ;  the  dilatation  of  the 
affected  side, — are  in  striking  contrast  with  signs  most  manifest  at 
the  apex,  with  the  distinctly -prolonged  expiration,  with  the  rales 
and  the  evidences  of  beginning  softening.  Nor  are  the  symptoms 
of  a  pleuritic  effusion  as  grave  as  those  produced  by  phthisis. 
Even  where  the  fluid  filling  the  chest  is  pus,  we  do  not  find  hectic 
fever  so  intense,  emaciation  so  great,  or  night-sweats  so  constant 
and  exhausting ;  and  the  patient  coughs  less,  and  never  spits  up 
blood.  In  those  cases  of  chronic  pleurisy  in  which  the  side,  in- 
stead of  being  dilated,  is  retracted,  the  diagnosis  is  more  difficult. 
Attention  to  the  seat  of  dulness  being  at  the  lower  part  of  the 
chest,  to  the  diminished  respiration,  voice,  and  fremitus,  and  to 
the  shrinking  affecting  only  one  side  of  the  thorax,  will,  how- 
ever, serve  as  the  foundation  for  a  correct  conclusion. 

Tubercle  may  complicate  pleuritic  effusions.  We  suspect  this 
by  the  occurrence  of  hemorrhage,  and  by  the  marked  emaciation 
and  hectic.  We  can  only  be  sure  of  it  by  finding  signs  of  deposit 
on  the  non-affected  side,  which  deposit,  in  accordance  with  the 
custom  of  tubercular  disease,  will  take  place  first  at  the  apex. 
Chronic  double  pleurisy  is  very  apt  to  be  associated  with  a  tuber- 
cular affection  of  the  lungs. 

Pulmonary  Cancer. — Cancer  of  the  lung  has  many  symptoms 
which  it  shares  with  tubercle.  Cough,  night-sweats,  hemorrhage, 
gradual  wasting,  belong  to  both  diseases,  as  do  the  signs  of  pulmo- 

*  See  paper,  Phila.  Med.  Times,  June  19,  1880. 


DISEASES    OF    THE    LUNGS.  293 

nary  consolidation.  But  cancerous  formations  are  usually  limited 
to  one  lung.  Only  one  side  of  the  chest  is,  therefore,  flattened 
or  distended.  Over  the  cancerous  lung  the  percussion  dulness  is 
great.  There  is  either  loud,  blowing  respiration,  or,  if  the  mass 
have  compressed  or  obliterated  a  bronchus,  enfeebled  or  absent 
breathing.  We  find  no  rales;  but  all  the  signs  of  consolidation 
are  more  perfect  than  in  tubercle.  Owing  to  a  cancerous  deposit 
in  the  mediastinum,  the  dulness  at  times  extends  beyond  the  me- 
dian line.  Cancer  in  the  lung  may  soften  ;  yet  the  signs  of  soft- 
ening are  rarely  as  manifest  as  they  are  in  tubercle.  The  sputa 
are  purulent,  or  like  currant-jelly.  Further,  a  cancerous  tint  of 
the  skin  may  be  present;  and,  again,  cancerous  tumors  in  other 
parts  of  the  body  become  next  to  absolute  evidence  in  favor  of  a 
deposit  in  the  lung  being  cancerous,  since,  with  very  rare  excep- 
tions, cancer  and  tubercle  do  not  coexist.  The  character  of  the 
pain  must  also  be  taken  into  account.  In  tubercle,  it  is  transitory 
and  shifting;  in  cancer,  it  is  much  more  constant,  and  much  more 
severe.* 

Syphilitic  Disease  of  the  Lungs. — Syphilis  may  lead  to  tubercular 
disease  of  the  lungs.  But  it  will  also  occasion  a  specific  form  of 
bronchitis,  preceding  the  syphilitic  eruption;  or  produce  gum- 
mata,  which  may  soften  and  be  eliminated,  and  which,  according 
to  Bicord,  form  in  the  lungs  toward  their  periphery  and  base. 
When  syphilis  manifests  itself  in  the  pulmonary  structures,  it 
gives  rise  to  most  of  the  phenomena  of  phthisis.  The  chief 
differences  are,  that  the  nodules  affect  generally  only  one  lung, 
and  principally  the  base  or  the  lower  part  of  the  upper  lobe,  that 
they  remain  circumscribed,  not  spreading  to  the  surrounding  tex- 
tures, and  that  they  occasion,  as  a  rule,  neither  haemoptysis,  nor 
fever,  nor  decided  emaciation,  nor  marked  cough  or  rales.  The 
most  common  physical  signs  are  dulness  on  percussion,  deficient 
fremitus,  altered  vesicular  breath-sounds,  and  obvious  sinking  in 
of  the  supra-  and  infra-clavicular  regions.  Still,  the  syphilitic 
affection  can  be  distinguished  with  certainty  only  by  the  history 
of  the  case,  and  by  the  thickening  of  the  periosteum  of  the  head 

*  Compare,  on  this  subject,  the  cases  collected  by  Bennett  in  his  Clinical 
Lectures;  by  Hughes,  Guy's  Hospital  Eeports,  1st  Series,  vol.  ii. ;  by  Stokes, 
Dubl.  Journ.  of  Med.,  vol.  xxi. ;  by  James  Eisdon  Bennett,  Intra-Thoracic 
Growths,  London,  1872;  by  Meissner,  Schmidt's  Jahrbiicher,  1879,  No.  4. 


294  MEDICAL    DIAGNOSIS. 

of  one  or  both  clavicles.  Milroy,*  in  his  investigations  on  soldiers, 
also  lays  stress  on  the  thickening  of  the  perichondrium  of  one  or 
more  of  the  upper  cartilages,  with  frequently  a  tumefaction  of  the 
soft  parts  between  them  and  the  skin.  To  these  tests  may  be 
added  that  recognized  by  Broderick,t  substernal  tenderness,  as  a 
means  of  diagnosis  of  acquired  syphilitic  taint.  In  all  cases,  we 
must  be  careful  that  the  thickening  at  the  upper  part  of  the  chest- 
walls  and  the  altered  resonance  thus  occasioned  be  not  looked  upon 
as  signs  of  a  tubercular  consolidation.  And  as  regards  the  tender- 
ness,  pain  on  pressure,  as  has  been  correctly  asserted,  is  met  with 
at  the  lower  part  of  the  sternum  in  a  large  number  of  phthisical 
cases.  The  former  assistants  at  my  clinic,  Dr.  James  Wilson  and 
Dr.  Engel,  for  a  long  time  examined  into  this  point,  and  found  it 
very  constant. 

The  preceding  diseases  are  most  likely  to  be  confounded  with 
the  stages  of  consumption  prior  to  softening  and  the  formation  of 
cavities.  Xext  let  us  review  those  affections  which,  like  phthisis, 
occasion  the  signs  of  excavation,  and  which,  therefore,  may  be 
mistaken  for  its  third  stage  :  they  are,  chiefly,  bronchial  dilatation, 
abscess,  and  gangrene  of  the  lung. 

Bronchial  Dilatation. — A  dilatation  of  the  bronchial  tubes  takes 
place  in  two  forms :  either  the  tubes  are  uniformly  dilated  and 
like  the  fingers  of  a  glove,  or  else  they  form  cavities  by  undergoing 
a  saccular  enlargement.  The  former  variety  furnishes  the  symp- 
toms and  physical  signs  of  a  case  of  chronic  bronchitis  attended 
with  copious  expectoration.  The  percussion  clearness  may  be 
slight! v  lessened,  owing  to  the  condensation  of  the  surrounding 
pulmonary  tissue;  the  respiration  may  be  more  strictly  bronchial ; 
but  otherwise  both  symptoms  and  signs  are  those  of  chronic  bron- 
chial inflammation.  In  the  globular  form  of  dilatation,  we  meet 
with  all  the  sounds  of  tubercular  excavations:  the  hollow,  blowing 
respiration;  the  hollow,  well-transmitted  voice;  gurgling;  even 
metallic  tinkling.  Yet  all  these  phenomena  are  in  strange  contrast 
with  the  almost  unimpaired  health,  and  with  the  non-occurrence 
of  hemorrhage,  of  night-sweats,  and  of  emaciation. 

Hence,  when  we  find  the  signs  of  a  cavity,  and  when  the  general 

*  British  Army  Medical  Report,  quoted  in  Annals  of  Military  and  Xaval 
Surgery,  vol.  i.,  1863. 

t  Madras  Medical  Journal,  July,  I860. 


DISEASES    OF    THE    LUXGS.  295 

symptoms  do  not  indicate  that  profound  constitutional  disturbance 
with  which  consumption  is  associated,  we  may  suspect  a  bronchial 
dilatation.  This  suspicion  becomes  a  certainty,  if  the  cavity  be 
at  the  middle  or  the  lower  portion  of  the  lung,  and  if  the  resonance 
on  percussion  be  but  little  impaired.  For  it  is  settled  beyond 
doubt  that,  in  bronchial  dilatation,  the  dulness  over  the  seat  of 
the  disease  is  very  slight;  certainly  not  nearly  so  great  as  that 
yielded  by  the  dense  walls  of  a  tubercular  excavation.  It  is  also 
true  that  the  dulness  on  percussion  is  not  increased  by  respiratory 
percussion,  and,  for  the  most  part,  follows,  and  does  not  precede, 
the  auscultatory  phenomena  of  a  cavity.  We  find  further  evidence 
of  the  affection  not  being  tubercular,  in  the  stationary  character 
of  the  physical  signs :  for  months  they  do  not  change ;  whereas 
in  phthisis  they  continually  alter  with  the  advancing  malady. 
The  expectoration  of  bronchial  dilatation,  too,  is  more  abundant 
than  that  of  consumption,  and  in  very  chronic  cases  fetid,  sug- 
gesting, indeed,  at  times,  the  existence  of  gangrene.  Nor  does  it 
look  like  the  sputum  of  phthisis,,  for  the  bulk  of  it  is  much  more 
fluid,  and  in  the  watery  secretion  float  small  masses  of  pus  and 
detritus  far  less  compact  than  the  nummular  sputum  of  phthisis. 
As  regards  the  cough  of  dilated  bronchi,  it  is  much  more  persist- 
ent, being  constant  by  day  and  by  night,  and  only  at  times  relieved 
by  expectoration,  which  then  varies  in  copiousness  according  to 
the  size  of  the  sac* 

Skodaf  describes,  as  a  peculiar  physical  sign  present  in  saccu- 
lated bronchial  dilatation,  a  large  and  coarse  crackling,  called  by 
him  the  large  bubbling,  dry  crepitant  rale.  In  a  case  which  came 
under  my  observation,  the  diagnosis  was  made  by  this  auscultatory 
sign.  The  patient,  a  boy  aged  twelve  years,  had  swallowed  a 
bone,  which  lodged  in  a  bronchial  tube  and  gave  rise  to  bron- 
chitis and  bronchial  widening.  He  died  subsequently  of  acute 
meningitis,  and  the  bone  was  found  firmly  imbedded  on  one  side 
of  the  globularly-dilated  bronchial  tube. 

Pulmonary  Abscesses. — The  circumstance  that  cavities  or  ab- 
scesses in  the  lung-tissue  are  so  generally  caused  by  softening 
tubercles,  makes  physicians  overlook  the  fact  that  abscesses  of  the 


*  Skoda,  Allgem.  "Wien.  Mediz.  Zeitung,  1864,  STo.  26. 
f  Perkussion  und  Auskultation. 


296  MEDICAL    DIAGNOSIS. 

lung  occur  unconnected  with  tubercular  disease.  Such  abscesses 
may  form  in  the  course  of  acute  pneumonia,  but  are  not  then 
likely  to  be  mistaken  for  chronic  phthisis.  Different  is  it  with 
abscesses  which  are  developed  three  or  four  months  after  an  attack 
of  pneumonia,  and  where  the  lung-texture  has  remained  partially 
consolidated.  I  have  seen  not  a  few  examples  of  chronic  indura- 
tion of  the  lung  terminating  in  this  way.  A  man  who  was  shot 
through  the  lung  was  seized,  soon  after  the  injury,  with  inflam- 
mation of  that  organ.  Percussion  dulness  and  blowing  respira- 
tion continued  at  the  lower  part  of  the  left  lung,  notwithstanding 
all  efforts  to  remove  the  lymph  which  caused  them.  One  day, 
after  exertion,  he  suddenly  expectorated  a  considerable  amount 
of  pus.  The  signs  of  a  cavity  were  detected  at  once;  but  they 
have  since  disappeared,  and  perfect  recovery  has  taken  place.  In 
another  case  of  pneumonia,  the  disease  in  like  manner  lapsed  into 
a  chronic  state.  Five  months  after  the  acute  attack,  the  evidences 
of  an  excavation  became  manifest  at  the  edge  of  the  right  scapula, 
and  existed  there  for  two  months ;  then,  as  far  as  physical  signs 
could  prove,  the  cavity  closed.  Instead  of  the  hollow,  blowing 
respiration  and  gurgling,  only  a  somewhat  roughened  vesicular 
murmur  was  perceived. 

Such  is,  however,  not  always  the  termination.  The  abscess 
may  grow  larger  and  larger,  until  the  entire  lung,  as  proved  by 
post-mortem  examination,  is  destroyed. 

These  abscesses  differ  from  bronchial  dilatation  in  not  being 
permanent  and  fixed.  They  have  this  in  common  with  tubercular 
excavations — they  change.  They  increase  like  these;  but,  further, 
they  do  what  tubercular  cavities  do  not — they  decrease.  Their 
physical  signs  are  in  every  respect  like  those  of  all  cavities,  and 
vary  with  the  size  of  the  excavation.  Sometimes  metallic  respira- 
tion and  voice  may  be  heard  over  it ;  or  perforation  of  the  pleura 
produces  the  signs  of-  pneumothorax  with  effusion.  In  fortunate 
instances  the  pus  is  expectorated,  or  the  abscess  opens  externally, 
ami  a  cure  is  thus  established.  But  very  large  abscesses  are  apt 
to  wear  out  the  patient.  Hectic  fever,  and  occasional  hemorrhage, 
attend  them;  yet  neither  is  as  constant  a  symptom  as  it  is  in  con- 
sumption. The  sputa  are  usually  copious,  purulent,  and  very  fetid, 
differing  in  this  respect  from  the  expectoration  of  phthisis.  Again, 
abscess  of  the  lung  may  be  distinguished  from  tubercular  disease 


DISEASES    OF    THE    LUNGS.  297 

by  being  ordinarily  situated  at  the  base  of  the  organ ;  by  its  fol- 
lowing— although  there  are  exceptions  to  this  rule — pneumonic 
consolidation;  by  the  occurrence  of  copious  expectoration  being 
often,  not  constantly,  sudden;  but  especially  by  its  limitation  to 
one  lung.  The  other  lung  remains  perfectly  healthy.  It  may 
enlarge,  and  its  murmur  be  more  distinct ;  but  all  its  movements 
and  sounds  denote  its  texture  to  be  normal. 

The  small  amount  of  constitutional  disturbance  which  pul- 
monary abscesses  sometimes  entail  is  remarkable.  In  several 
patients,  in  whom  I  have  noticed  abscess  of  the  lung  consequent 
upon  chronic  pulmonary  consolidation,  the  physical  signs  of  a 
large  cavity  were  in  strange  contrast  with  the  regular  pulse,  the 
easy  breathing,  the  slight  cough,  and  the  healthy  complexion. 

Let  us  tabulate  the  differences  between  a  tubercular  excavation 
and  a  pulmonary  abscess  : 

Pulmonary  Abscess.  Catity  from  Phthisis. 

Signs  of  cavity  usually  at  the  lower  Signs  in  the  upper  lohe. 

lobe. 

Copious  and  purulent  sputa.  Sputa  less  copious  ;  and  at  first  num- 
mular. 

Comparatively  small  amount  of  con-  Graver    symptoms,   and    a    different 

stitutional  disturbance.  history. 

One  lung  affected.  Usually  both  lungs  affected. 

Pulmonary  Gangrene. — Another  disease  which  yields  the  signs 
of  an  excavation,  and  which,  like  phthisis,  is  attended  with  wasting 
of  the  body,  here  claims  attention.  Gangrene  of  the  lung  occurs 
either  as  diffused  or  as  circumscribed  gangrene,  after  pneumonia, 
after  wounds  of  the  lung,  from  blows  on  the  chest,  from  poisoned 
blood,  or  from  emboli  in  the  pulmonary  tissue.  The  physical 
signs  are  those  of  a  cavity,  seated  usually  in  the  lower  portion  of 
the  lung.  The  symptoms  are :  great  and  increasing  prostration, 
dyspnoea,  a  very  pale  face,  a  quick  pulse,  hemorrhage,  emaciation, 
and  a  cough,  followed  by  profuse  purulent  sputa  of  a  greenish 
or  brown  color.  But  nearly  all  these  symptoms  happen  also  in 
phthisis.  What  is  characteristic  of  gangrene  is  the  extreme  fetor 
of  the  expectoration  and  of  the  breath.  The  sickening  odor  is  not 
perceived  during  each  act  of  breathing,  but  mainly  after  coughing, 
and,  as  it  were,  in  jets.  It  is  the  symptom  by  which,  especially 
if  taken  in  connection  with  the  signs  of  breaking  up  of  the  pul- 


298  MEDICAL    DIAGNOSIS. 

monary  tissue  and  the  sputum,  gangrene  is  with  certainty  recog- 
nized. Some  authors  lay  stress  on  the  fact  that  a  cavity  is  found 
in  only  one  lung,  and  at  its  lower  part.  This  is  unquestionably 
of  aid  in  discriminating  between  phthisis  and  gangrene;  but  it 
does  not  distinguish  between  a  gangrenous  excavation  and  a  simple 
abscess  of  the  lung.  The  only  positive  proof  of  gangrene  of  the 
lung  is,  as  just  stated,  that  the  signs  of  breaking  down  of  the  pul- 
monary tissue  are  accompanied  by  a  disgusting  and  more  or  less 
persistent  fetor  of  the  expectoration  and  of  the  breath  ;  sometimes 
a  sickening,  faintly  sweetish  smell,  sometimes  fecal,  oftener  that  of 
putrescence.  I  say  persistent,  because  local  gangrene,  on  a  small 
scale,  occurring  around  tubercular  cavities  or  in  bronchitis,  may 
give  rise  to  temporary  extreme  fetor  of  the  breath.  But  it  is  only 
temporary,  and  therefore  not  liable  to  lead  to  fallacious  inferences. 
The  expectoration  may  be  fetid  in  cases  of  bronchial  dilatation  or 
of  abscess  of  the  lung,  but  is  never  brownish,  as  is  not  uncommon 
in  gangrene ;  and  neither  it  nor  the  breath  has  that  peculiar  gan- 
grenous odor  which  makes  the  patient  as  unbearable  to  himself 
as  to  his  attendants.  In  rare  instances  pleurisy  with  fetid  effu- 
sion may  occasion  a  fecal  smell  of  the  expectoration  and  breath, 
which  is  gradually  lost.* 

Yet,  in  making  the  statement  about  bronchial  dilatation,  we 
must  not  overlook  the  fact  that,  as  Dittrich  and  Traubef  have 
shown,  it  bears  a  marked  relation  to  gangrene.  Decomposition 
takes  place  in  the  secretions  retained  in  the  bronchial  dilatation, 
and  ulceration  of  the  coats  may  ensue,  leading  to  a  gangrenous 
process  in  the  surrounding  tissue.  Now,  as  just  mentioned,  the 
sputum  even  in  bronchial  dilatation  may  become  from  this  decom- 
position very  fetid.  As,  moreover,  it,  like  gangrenous  sputum, 
may  present  a  dirty  greenish-yellow  color,  and  separate  on  stand- 
ing into  three  distinct  strata,  of  which  the  uppermost  is  frothy 
though  dense,  the  second  serous,  and  the  third  dense,  containing 
pure  pus  and  detritus ;  as,  further,  we  meet  in  both  affections  with 
little  solid  masses  of  particularly  offensive  odor  full  of  fat  and 
fine  needle-shaped  crystals  of  margaric  acid, — we  may  have  to 
depend,  for  a  differential  diagnosis,  on  finding  with  the  microscope 

*  As  in  the  case  reported  by  Dr.  William  Moore  (Dubl.  Quart.  Journ.,  May, 
1865). 
j  Gesammelte  Abhandlungen. 


DISEASES    OF    THE    LUNGS.  299 

masses  of  degenerated  lung-texture.  Bacteria  and  vibriones  be- 
speak a  similar  pulmonary  origin,  and  they  and  the  substance  in 
which  they  are  imbedded  yield  a  purple  or  blue  reaction  with 
iodine.* 

The  complaints  just  considered  exhibit,  thus,  points  in  which 
they  are  similar,  and  points  in  which  they  are  dissimilar,  to  pul- 
monary consumption.  Other  affections  might  be  added  which  are 
sometimes  mistaken  for  this  malady,  such  as  anaemia,  dyspepsia, 
chronic  diarrhoea,  chronic  laryngitis,  chronic  pharyngitis,  and 
thoracic  pains.  But  each  of  these,  although  it  may  accompany 
tubercular  consumption  and  even  mask  some  of  its  symptoms, 
lacks,  when  it  is  present  as  an  idiopathic  affection,  those  local 
evidences  of  deposition  and  softening,  lacks  that  profound  con- 
stitutional disturbance,  which  form  as  much  a  part  of  phthisis  as 
the  disease  in  the  lungs.  It  is,  moreover,  very  likely  that  we 
shall  find  the  higher  temperature  the  thoracic  malady  shows  on 
the  chest-walls  a  valuable  sign  even  in  early  and  doubtful  cases. 

In  the  remarks  on  the  diagnosis  of  pulmonary  consumption, 
the  complaint  has  been  assumed  to  be  progressive ;  in  rare  in- 
stances it  retrogrades.  Now,  before  dismissing  the  subject  of 
phthisis,  the  signs  by  which  such  retrogression  can  be  discovered 
may  be  alluded  to.  They  are  not  very  fixed.  In  those  cases  in 
which  many  tubercles  undergo  a  cretaceous  transformation,  calca- 
reous particles  are  coughed  up ;  the  signs  of  softening  cease ;  the 
apex  flattens ;  and  a  feeble  murmur,  with  prolonged  expiration  or 
a  harsh  respiration,  with  slight  dulness  on  percussion,  is  all  that 
remains  to  indicate  that  tubercular  disease  has  existed.  It  is 
hardly  necessary  to  say  that  the  cough  stops,  and  that  flesh  and 
strength  return.  These  phenomena  may  be  noted  even  when 
large  cavities  have  existed.  But,  unfortunately,  it  is  not  often 
that  we  have  opportunities  to  make  such  observations. 

We  meet  occasionally  with  instances  in  which  the  physical  signs 
of  an  infiltration  into  the  lung-tissue  depart  with  tolerable  rapid- 
ity. They  occur  in  those  who  have  a  decidedly  scrofulous  aspect, 
enlargement  of  the  glands  of  the  neck,  or  a  scrofulous  inflamma- 
tion of  the  eyes.  In  accordance  with  the  generally  acknowledged 
identity  of  scrofula  and  tubercle,  we  should  be  forced  to  admit 

*  Leyclen.  Klinische  Yortriige,  No.  26,  1871. 


300  MEDICAL   DIAGNOSIS. 

that  the  disease  in  the  lungs  is  tubercular.  Yet  the  connection 
with  the  enlarged  lymphatics;  the  circumstance  that  the  diminu- 
tion in  size  of  the  glands  is  often  followed  by  increased  pulmonary 
deposits ;  that  these  depositions  are  very  beneficially  influenced  by 
treatment ;  that  they  disappear  sometimes  altogether,  or  only  re- 
appear months  afterward, — all  make  it  a  question  whether  there 
be  not  a  scrofulous  disease  of  the  lung  independent  of  a  tubercular, 
and  one,  moreover,  which  presents  a  much  more  favorable  prog- 
nosis. Among  the  scrofulous  children  who  throng  our  public 
institutions,  cases  like  those  alluded  to  are  not  uncommon.  The 
disorder  certainly  differs  from  the  ordinary  forms  of  pulmonary 
tuberculosis,  and  it  is  not  bronchial  phthisis.  It  does  not  present 
the  paroxysmal  cough,  the  signs  of  pressure  on  the  trachea  or  the 
large  bronchi,  and  the  dull  sound  on  percussion  between  the 
scapula?,  which  are  the  common  accompaniments  of  enlarged  and 
tubercularized  bronchial  glands. 

Some  years  since,  I  had  an  opportunity  of  inspecting  the  lungs 
in  one  of  these  instances  of  supposed  pulmonary  scrofula.  I  was 
treating  a  little  girl  for  this  affection,  when  she  received  a  severe 
injury  which  resulted  in  her  death.  She  had,  when  first  seen,  an 
eruption  on  the  scalp,  sore  eyes,  and  enlarged  cervical  glands.  She 
was  also  much  troubled  by  a  cough ;  and  marked  d illness  on  per- 
cussion was  discerned  at  the  upper  portion  of  the  left  lung.  Here, 
as  in  fact  throughout  the  whole  of  the  left  lung  and  the  upper 
part  of  the  right,  the  respiration  was  harsh.  But  for  two  weeks 
before  her  death  the  symptoms  and  signs  had  strikingly  improved 
under  cod-liver  oil  and  iodide  of  iron.  She  was  rapidly  losing 
her  cough  and  gaining  strength.  The  dulness  on  percussion  was 
diminishing,  the  respiration  becoming  less  and  less  rough.  At  the 
autopsy  the  greater  part  of  the  left  lung  and  a  portion  of  the  right 
were  found  to  contain  yellowish,  cheesy  deposits,  which  exhibited 
under  the  microscope  a  large  quantity  of  granules  and  some 
shrivelled  cells,  without  distinct  nuclei. 

It  would  be  out  of  place  to  pursue  here  this  intricate  subject. 
I  shall  only  add  that  there  are  no  phenomena  which  serve  as  a 
foundation  for  an  absolute  diagnosis  of  a  scrofulous  in  distinction 
from  a  tuberculous  infiltration.  But  the  rapid  fluctuation  in  the 
physical  signs,  their  occurrence  in  those  who  present  a  strongly 
scrofulous  aspect,  and  the  course  of  the  disease,  may  furnish  a 


DISEASES    OP    THE    LUNGS.  301 

clue  by  which  to  separate,  as  far  as  they  can  be  separated,  cases  of 
these  kindred  disorders.  Perhaps  the  absence  of  haemoptysis  from 
among  the  symptoms  may  turn  out  to  be  a  matter  of  much  im- 
portance in  a  diagnostic  point  of  view.  Certainly  hemorrhage  did 
not  happen  in  any  of  the  cases  of  pulmonary  scrofula  which  have 
come  under  my  observation. 

The  Acute  Affections  of  the  Lungs  accompanied  by  Dulness  on 
Percussion. 

In  continuing  the  consideration  of  the  diseases  in  which  dulness 
on  percussion  is  a  marked  sign,  let  us  glance  at  a  group  of  acute 
affections,  in  the  distinction  of  which  dulness  and  the  physical 
sounds  which  correspond  to  it  hold  an  important  part. 

The  acute  diseases  affecting  that  portion  of  the  respiratory 
apparatus  which  lies  within  the  chest  are  bronchitis,  pneumonia, 
pleurisy,  and  acute  phthisis.  They  have  some  signs  and  many 
symptoms  in  common.  They  all  present  fever;  they  are  all 
associated  with  more  or  less  dyspnoea  and  thoracic  pain;  they 
all  occasion  a  cough.  If,  therefore,  a  practitioner  meet  with  an 
acute  disease  of  the  chest,  and  find  the  heart  healthy,  his  mind  is 
forcibly  directed  to  the  disorders  mentioned,  and  he  asks  himself, 
Is  the  malady  acute  bronchitis?  is  it  acute  phthisis ?  is  it  acute 
pneumonia  ?  is  it  acute  pleurisy  ? 

Now,  the  symptoms  and  signs  of  acute  bronchitis  have  already 
been  discussed.  It  has  been  pointed  out  that  the  want  of  intensity 
of  the  fever,  and  particularly  the  unimpaired  resonance  on  per- 
cussion, separate  bronchial  inflammation  from  all  affections  which 
occasion  consolidation  or  compression  of  the  lung-tissue.  Its 
further  consideration  among  diseases  accompanied  by  dulness  on 
percussion  would  be,  therefore,  evidently  out  of  place;  and  we 
may  proceed  to  examine  the  other  acute  pulmonary  affections. 

Acute  Phthisis. — When  phthisis  runs  its  course  rapidly,  it 
constitutes  the  malady  known  as  acute  phthisis,  or  galloping  con- 
sumption, or,  as  it  is  more  commonly  called  now,  acute  tubercu- 
losis. This  formidable  complaint  is  met  with  at  the  close  of  other 
diseases,  especially  of  fevers ;  but  exposure,  toil,  and  anxiety  are 
also  among  its  exciting  causes. 

Acute  phthisis  shows,  more  even  than  chronic  pulmonary  con- 
sumption, that  the  disease  is  not  simply  one  of  the  lungs.     The 


302  MEDICAL   DIAGNOSIS. 

lesions  found  by  the  knife  of  the  pathological  anatomist  are  for 
the  most  part  insufficient  to  account  for  the  early  exhaustion  and 
the  emaciation,  and  indicate  a  constitutional  affection,  of  which 
the  tubercles  in  the  lungs  are  but  the  local  expression. 

The  disorder  often  begins  with  a  severe  chill :  fever  follows ;  at 
first  like  any  inflammatory  fever  with  thirst,  anorexia,  quickened 
pulse,  parched  lips,  and  hot  skin,  but  soon  accompanied  by  ex- 
hausting night-sweats  and  rapid  emaciation,  which,  in  connection 
with  the  intense  restlessness  and  prostration,  and  the  frequent 
supervention  of  delirium,  may  cause  the  febrile  disturbance  closely 
to  resemble  typhoid  fever.  The  symptoms  which  point  to  the 
thoracic  malady  are  the  accelerated  breathing,  the  cough,  the 
copious  expectoration,  the  pain  in  the  chest,  and  the  spitting  up 
of  florid  blood. 

The  physical  signs  are  not  always  the  same.  If  the  tubercles 
be  scattered  through  the  lungs,  no  signs  are  perceived  but  those  of 
diffused  acute  bronchitis.  More  commonly  the  signs  are  like  those 
of  chronic  pulmonary  phthisis,  and  associated  with  the  fever  and 
prostration  we  find  the  percussion  dulness  of  a  deposit  or  the 
evidences  of  the  breaking  up  and  destruction  of  the  pulmonary 
tissue,  furnished  by  coarse,  moist  rales,  and  cavernous  breathing. 

"When  the  malady  assumes  the  form  resembling  chronic  pul- 
monary consumption,  the  diagnosis  from  bronchitis  is  not  per- 
plexing ;  but  when  its  phenomena  are  similar  to  those  of  acute 
bronchitis,  the  recognition  of  the  tubercular  affection  is  often 
impossible.  This  remark  applies  particularly  to  the  distinction 
of  the  miliary  form,  acute  miliary  tuberculosis,  from  capillary  bron- 
chitis ;  since  the  slight  constitutional  symptoms  and  the  coarseness 
of  the  rales  of  ordinary  bronchial  inflammation  are  too  unlike  the 
phenomena  of  acute  consumption  to  occasion  commonly  much 
difficulty  in  their  discrimination.  But  from  bronchitis  of  the  finer 
tubes  the  diagnosis  can  only  be  effected  by  taking  into  account 
that  repeated  chills,  rapid  emaciation,  and  profuse  sweats  are 
wanting  in  the  bronchial  affection ;  that  the  temperature  is  not 
so  high,  nor  so  irregular;  that  the  skin  is  more  livid;  that  the 
rales  are  more  abundant  and  more  perceptible  at  the  lower  part 
of  the  chest ;  and  that,  perhaps,  the  breathing  is  usually  not  so 
hurried.  Moreover,  with  the  great  dyspnoea,  there  are  generally 
frequent  and  violent  fits  of  coughing,  and  marked  chest  pains,  in 


DISEASES    OF    THE    LUNGS.  303 

the  acute  tubercular  malady.  Yet  none  of  these  signs  are  con- 
vincing proofs.  The  presence  of  d ulness  on  percussion,  or  the 
sinking  in  at  the  upper  part  of  the  chest,  the  occurrence  of  hem- 
orrhage, and  the  longer  duration  of  the  case  are  alone  conclusive 
evidence  in  favor  of  acute  tubercular  disease.  Hemorrhage  is, 
however,  by  no  means  so  constant  in  the  acute  as  in  the  chronic 
form  of  the  affection. 

Much  the  same  symptoms  will  enable  us  to  distinguish  between 
acute  tuberculosis  of  the  miliary  form  and  catarrhal  pneumonia, 
except  that  we  can  draw  no  inference  from  the  dulness  on  per- 
cussion, further  than  that  its  early  occurrence,  with  the  bronchial 
symptoms,  points  to  the  pneumonic  malady,  its  later  occurrence, 
after  the  grave  symptoms,  to  the  tubercular. 

When  the  dulness  on  percussion  is  well  defined,  acute  phthisis 
might  be  mistaken  for  ordinary  pneumonia.  But  the  signs  of 
deposit  and  of  softening  in  both  lungs,  and  the  seat  of  the  lesions 
at  the  apices,  show  differences  from  a  disease  which  in  the  large 
majority  of  instances  is  one-sided  and  at  the  lower  part  of  the  lung, 
which  exhibits  a  characteristic  sputum,  and  in  which  breaking  up 
of  the  pulmonary  tissue  is  so  rare. 

Yet  there  are  cases  of  acute  phthisis  that  display  symptoms  and 
signs  very  puzzling,  and  strongly  simulating  those  of  pneumonia. 

A  person  in  perfectly  good  health  is  seized,  after  exposure,  with 
cough  and  fever.  They  are  accompanied  by  dyspnoea,  and  soon 
we  find  signs  of  consolidation  of  the  lower  lobe,  or  of  the  entire 
lung.  The  dulness  on  percussion  does  not  disappear  under  treat- 
ment ;  and  a  hollow,  blowing  respiration  and  gurgling,  usually 
first  perceptible  at  the  angle  of  the  scapula,  gradually  appear, 
and  indicate  the  formation  of  a  cavity.  Emaciation,  which  began 
from  the  onset,  progresses  more  rapidly,  and  goes  hand  in  hand 
with  extreme  prostration  and  profuse  perspirations.  The  sputa 
are  copious  and  purulent,  but  at  no  time  mixed  with  blood.  The 
other  lung  is  carefully  examined ;  all  its  sounds  are  normal.  The 
case  remains  in  this  condition  for  several  weeks,  the  patient  tem- 
porarily improving  under  stimulants,  yet,  on  the  whole,  growing 
weaker  and  tormented  with  fever  of  very  irregular  type.  A  slight 
roughening  of  the  inspiratory  murmur,  or  dry  rales  at  the  apex  of 
the  unaffected  lung,  attract  attention,  and  dulness  on  percussion 
and  the  signs  of  deposition  become  there  more  and  more  manifest. 


304  MEDICAL    DIAGNOSIS. 

A  post-mortem  examination  exhibits  nearly  the  whole  of  one  lung 
converted  into  a  uniform  yellowish  or  grayish  mass  of  tubercle, 
and  containing  one  or  several  large  excavations;  not  a  vestige  of 
healthy  lung-structure  is  to  be  seen.  Scattered  tubercles  are  found 
in  the  other  lung,  and  mainly  at  its  apex. 

The  case  just  described  is  one  of  a  group  which  every  physician 
must  have  met  with.  The  beginning  of  the  case  as  one  of  pneu- 
monia or  catarrhal  pneumonia,  the  persistent  consolidation,  the 
occurrence  of  rales  and  of  subsequent  dulness  on  percussion  at  the 
upper  part  of  the  previously  unaffected  side,  the  continuance  of 
the  disease,  and  the  prostration  and  sweats  which  accompany  it, 
permit  us  to  foretell  its  nature  and  the  probable  fatal  termination. 

I  may,  in  this  connection,  again  revert  to  the  views  of  those 
who,  like  Niemeyer,  accord  to  inflammation  and  the  degeneration 
of  its  products  the  chief  place  in  the  production  of  consumption. 
Such  cases  as  just  described  would  be  classed  as  acute  galloping 
consumption,  acute  pneumonic  phthisis,  the  result  of  caseous  in- 
filtration of  the  pulmonary  tissues  and  the  disintegration  of  the 
cheesy  infiltration.  On  the  other  hand,  in  true  acute  tuberculosis 
an  eruption  of  miliary  tubercles  in  the  lungs  and  in  most  other 
organs  takes  place,  there  are  repeated  chills,  and,  as  already 
stated,  the  febrile  symptoms  run  very  high,  the  dyspncea  is  in- 
tense, but  the  physical  signs  are  usually  more  those  of  an  extensive 
bronchitis. 

Acute  phthisis  may  simulate  other  affections  besides  those  of 
the  chest.  It  has  at  times  the  delirium  and  prostration,  the  dry 
tongue,  and  the  bronchial  rales  of  typhoid  fever.  The  diarrhoea 
and  the  abdominal  symptoms  are,  however,  wanting.  Yet  simul- 
taneous deposition  of  tubercles  in  the  intestine  may  cause  these; 
and  in  this  case  the  only  mark  of  difference  from  typhoid  fever 
is  the  absence  of  an  eruption;  unless,  even  under  these  circum- 
stances, we  are  aided  by  the  fact  pointed  out  by  Fox,*  namely, 
that,  unlike  the  persistent  high  temperature  of  typhoid  fever 
with  its  regular  diminution  when  the  disease  declines,  the  thermo- 
metric  record  in  acute  phthisis  shows  great  and  sudden  variations 
of  animal  heat,  bearing  no  regular  relation  to  the  number  of  res- 
pirations or  to  the  beats  of  the  pulse.    The  temperature  may  vary 

*  St.  George's  Hospital  Reports,  1869. 


DISEASES    OF    THE    LUNGS.  305 

many  times  in  the  course  of  the  disease  to  the  extent  of  six  or 
seven  degrees.  Acute  phthisis  lacks  the  wild  eye,  the  gastric  dis- 
turbance, the  convulsions,  of  meningitis ;  or  the  active  delirium  it 
occasionally  produces  might  be  attributed  to  inflammation  of  the 
membranes  of  the  brain. 

Acute  phthisis  sometimes  progresses  with  extreme  rapidity.  I 
have  seen  a  case  terminate  in  thirteen  days.  It  is  almost  invari- 
ably fatal.  Yet  it  has  its  periods  of  deceptive  improvement:  the 
disease  may  proceed  speedily  toward  softening,  and  then  remain 
for  a  time  stationary.  In  some  instances  the  termination  in  death 
is  the  result  of  complications,  as  of  tubercular  meningitis,  or  of 
erysipelas  of  the  throat  and  the  bronchial  tubes.* 

Acute  Pneumonia. — Inflammation  of  the  lung,  or  "croupous 
pneumonia,"  as  it  is  often  called,  is  the  type  of  the  acute  pulmonary 
affections.  The  hot,  dry  skin,  the  flushed  face,  the  quickened 
pulse,  the  extremely  rapid  breathing,  the  thoracic  pain,  the  cough, 
and  the  peculiar  expectoration,  point  out  at  once  the  acute  nature 
of  the  attack  and  the  organ  which  is  disturbed.  Beginning  com- 
monly with  a  chill,  or  with  flushes  of  heat,  the  disease  progresses 
with  the  symptoms  indicated.  A  few  of  these  require  a  more 
detailed  description. 

The  expectoration  is  characteristic.  It  consists  at  first  of  a 
glairy  mucus;  soon  it  becomes  more  viscid,  and  acquires  that 
significant  appearance  dependent  upon  the  admixture  of  blood 
with  the  mucus  and  exudation- matter,  to  which  the  term  rusty- 
colored  has  been  given.  This  rusty  sputum  is  pathognomonic  of 
the  disorder;  yet  it  is  well  to  be  aware  that  cases  of  pneumonia 
run  their  course  without  it.  The  expectoration  is  sometimes  like 
prune-juice,  or  it  is  purulent.  Both  augur  badly:  both  indicate 
that  destruction  of  the  lung-tissue  has  begun. 

The  shortness,  or  increased  frequency,  of  breathing  is  another 
marked  symptom.  The  patient  draws  from  forty  to  eighty  breaths 
a  minute;  but  the  pulse,  although  rapid,  does  not  quicken  in 
proportion.  Pneumonia,  therefore,  forms  an  exception  to  the 
rule  that  with  greater  frequency  of  breathing  the  pulse  rises. 
This  perverted  pulse  respiration-ratio,  on  which  "Walshe  dwells, 
may  be  made  an  important  element  in  the  diagnosis.     The  febrile 


*  Lasegue,  Arch.  Gen.  <le  Med.,  May,  1873. 
20 


306  MEDICAL    DIAGNOSIS. 

symptoms  are  ordinarily  severe;  still,  they  are  not  associated  with 
decided  cerebral  disturbance.  Headache  is  common  ;  delirium  is 
rare,  and,  when  it  occurs,  is  indicative  of  great  danger.  The  heat 
of  the  skin  is  burning;  and  the  flush  on  the  cheek  so  decided 
that  by  this  and  the  hurried  breathing  alone  the  disease  may  often 
be  recognized.  The  flush  on'  the*  cheek  is  not  accidental.  It  is 
sometimes  very  dark,  and,  according  to  Bouillaud,  is  most  obvious 
when  the  inflammation  affects  the  apex  of  the  lung. 

The  urine  is  high-colored,  and  that  of  fever.  A  notable  cir- 
cumstance about  it  is  that  nitrate  of  silver  does  not  precipitate  its 
chlorides.  They  commonly  disappear  during  consolidation  of  the 
lung,  and  their  reappearance  shadows  forth  returning  health.  The 
vanishing  of  the  chlorides  from  the  urine  happens  also  in  other 
acute  affections ;  but  in  pneumonia  it  is,  perhaps,  most  constant 
and  most  absolute. 

The  physical  signs  which  denote  that  the  lung-tissue  has  be- 
come the  seat  of  an  acute  inflammation  may  be  deduced  from  a 
knowledge  of  the  effects  which  the  inflammation  occasions.  In 
the  first  stage,  or  that  of  engorgement,  occur  increased  vascularity 
and  beginning  exudation  in  the  air-cells,  into  which,  however, 
the  air  is  still  capable  of  entering.  There  is,  therefore,  only  a 
very  slight  impairment  of  the  normal  resonance  on  percussion. 
The  vesicular  murmur  is  at  first  somewhat  altered;  it  may  be 
feebler  or  harsher.  But  soon  are  heard  with  each  act  of  inspira- 
tion, and  limited  to  the  inspiration,  numerous  rapidly-evolved, 
very  fine,  crackling  sounds,  the  "crepitant"  or  vesicular  rales. 

As  the  exudation  becomes  firmer,  and  the  tissue  of  the  lung: 
solidifies  by  occlusion  of  the  air-cells,  the  stage  of  red  hepatization 
is  before  us.  Now  all  the  signs  of  complete  consolidation  are  dis- 
cerned. "We  find  decided  dulness  on  percussion,  unchanged  by 
full  inspiration  ;  blowing  respiration  in  its  purity,  high-pitched 
and  tubular-sounding;  bronchophony;  and  increased  vocal  fre- 
mitus. Bales  from  the  accompanying  bronchitis  are  heard  with 
extreme  distinctness  through  the  solidified  tissue  (Skoda's  con- 
sonating  rales) ;  so  are  the  sounds  of  the  heart.  A  crepitant  rale 
is  still  here  and  there  perceptible,  or  the  ear  catches  a  friction 
sound, — a  sign  that  inflammation  has  involved  the  pleura. 

"When  the  exudation  is  reabsorbed  or  expectorated,  the  signs  of 
consolidation  become  less  and  less  perfect.     A  vesiculobronchial 


DISEASES    OF    THE    LUNGS.  307 

succeeds  to  the  bronchial  breathing.  The  dulness  on  percussion 
lessens ;  crepitant  rales — not,  however,  so  fine  as  at  the  onset  of  the 
affection,  and  mixed  with  larger  moist  rales — return ;  the  cough  in- 
creases; the  expectoration  becomes  more  copious,  loses  its  tenacity 
and  rusty  color,  and  is  found  to  contain  broken-down  exudation- 

Fig.  26. 


Percussion  dulness... 
Bronchial  breathing. 

Bronchial  voice 

Increased  fremitus... 


Diagram  illustrative  of  perfect  pulmonary  consolidation,  such  as  happens  in  the 
second  stage  of  pneumonia. 

corpuscles  and  a  large  quantity  of  fat ;  the  dyspnoea  diminishes, 
— all  phenomena  indicative  of  the  breaking  up  of  the  exudation, 
and  of  the  return  of  air  into  the  vesicles.  If,  instead,  the  exuda- 
tion be  converted  extensively  into  pus,  and  the  lungs  soften,  the 
physical  signs  are  the  same  as  in  the  second  stage.  The  rarity  of 
excavations  of  sufficient  size  explains  why  gurgling  and  the  signs 
of  a  cavity  are  not  perceived.  We  suspect  the  mischief  that  is 
going  on  within  the  chest  from  the  protracted  dyspnoea,  the  in- 
creasing rapidity  of  pulse,  the  purulent  or  brownish  sputa,  the 
pinched  features,  the  dry  tongue,  and  the  mental  wandering.  Re- 
covery may  take  place  even  then.  This  third  stage  is  indeed  not 
so  much  an  abrupt,  suddenly  established  process,  as  it  is  the  ex- 
tension and  greater  diffusion  of  a  state  that  may  be  found  in  por- 
tions of  the  lung  which  to  the  eye  have  all  the  appearance  of  red 
hepatization.     In  every  instance  of  red  hepatization  the  micro- 


508 


MEDICAL   DIAGNOSIS. 


scope  shows  that  in  parts  the  lung-tissue  is  infiltrated  with  granules 
and  is  undergoing  softening,  and  it  is  probable  that  this  breaking 
down  occurs,  even  though  on  a  small  scale,  in  all  cases  of  pneu- 
monia which  recover.  These  minute  appearances  explain  why 
complete  gray  hepatization  is  rare;  why,  further,  it  is  often  im- 
possible to  fix  the  limits  of  the  second  stage  and  determine  that 
the  third  stage  has  arrived;  and  why  death  may  take  place  long 
before  the  lung  presents  the  condition  which  pathologists  term 
gray  hepatization.  It  is  indeed  a  great  mistake  to  suppose  that  a 
case  does  not  end  fatally  until  gray  hepatization  has  become  estab- 
lished, for  long  before  it  is  fairly  developed  death  may  ensue.  And 
with  reference  to  the  diagnosis  of  this  third  stage,  it  can  safely 
be  affirmed  that  we  may  suspect,  from  the  symptoms,  that  the 
pulmonary  tissue  is  seriously  damaged.  But  we  can  never  know 
it,  unless  we  find  the  physical  signs  of  extensive  softening ;  and 
in  the  large  majority  of  cases  this  cannot  be  done. 

The  morbid  phenomena,  physical  signs  and  symptoms  of  the 
malady  correspond  then  usually  in  this  manner : 


Pneumonia. 

I.  Stage  of  engorgement     Crepitant    rale;    slight 
and   beginning   ex-        percussion  dulness. 
udation. 


II.  Stage  of  solidifica- 
tion of  lung-tissue 
(red  hepatization). 


Percussion  dulness; 
bronchial  respiration ; 
bronchophony. 


Cough  ;  beginning  dysp- 
noea and  rapidly -de- 
veloped fever  heat. 

Puisty-colored  sputum ; 
dyspnoea;  cough;  high 
fever,  with  marked 
evening  exacerbations 
and     morninc;    remis- 


III.  Stage  of  soften- 
ing (gray  hepati- 
zation). 


The  same  physical  signs 
as  in  the  second  stage  ; 
unless  large  abscesses 
have  formed. 


Chills  ;  prostration,  etc. ; 
purulent  or  brown- 
ish sputum  ;  generally 
high  temperature. 


Here  is  a  disease  which  presents  such  striking  symptoms  and 
signs  in  nearly  all  its  phases,  in  which  the  sputa  are  so  peculiar, 
the  hurried  breathing  so  evident,  the  physical  signs  so  distinct, 
that  error  is,  with  ordinary  care,  difficult.  It  becomes  still  more 
so,  if  a  few  of  the  pathological  peculiarities  of  pneumonia  be 
borne  in  mind  :  the  fact  that  it  is  rarely  double ;  that  it  compara- 


DISEASES    OF    THE    LUNGS.  309 

tively  seldom  affects  the  upper  lobe  of  the  lung,  and  that  it  is 
often  accompanied  by  the  signs  of  slight  pleurisy  or  bronchitis. 

But  let  us  contrast  pneumonia  with  the  various  diseases  with 
which  it  may  be  confounded.  In  its  first  stage,  on  account  of 
similar  signs,  the  acute  inflammatory  disorder  is  sometimes  mis- 
taken for  cedema  of  the  lung,  or  for  the  pulmonary  engorgement 
which  takes  place  in  some  fevers ;  and  still  more  frequently  these 
morbid  states  are  mistaken  for  it. 

Pulmonary  (Edema. — This  consists  in  the  transudation  of  serum 
into  the  air-vesicles.  It  may  be  acute,  the  result  of  sudden  con- 
gestion, such  as  that  following  injuries  of  the  brain  or  irritation 
of  the  par  vagum ;  or  it  may  arise  at  the  termination  of  acute  affec- 
tions of  the  lungs.  It  is  more  usually,  however,  chronic,  and  is 
seen  as  a  dropsy  of  the  air-cells,  associated  with  dropsies  elsewhere, 
and  in  connection  with  organic  disease  of  the  liver,  heart,  or  kid- 
neys. The  characteristic  manifestations  of  oedema — be  it  acute 
or  chronic — are  embarrassed  breathing,  expectoration  of  frothy 
serum,  and  crepitating  and  fine  bubbling  sounds  diffused  over 
both  lungs,  and  dependent  upon  the  fluid  in  the  air-cells  and 
small  bronchial  tubes.  It  presents,  thus,  many  points  of  simi- 
larity to  the  first  stage  of  acute  pneumonia.  The  dyspnoea,  the 
crepitation  in  the  lung,  may  well  mislead ;  but  we  cannot  err,  if 
the  frothy  sputum,  the  general  distribution  of  the  rales,  their 
somewhat  coarser  character,  the  bluish  lip,  the  noisy  breathing, 
and  the  absence  of  fever  be  taken  into  account.  In  acute  oedema 
these  phenomena  are  but  the  precursors  of  death.  In  chronic 
cedema  the  rales  are  persistent,  and  so  is  the  difficulty  of  respira- 
tion. The  patient  has  usually  to  be  propped  up  with  pillows,  or 
he  cannot  breathe  at  all. 

Pulmonary  Engorgement  in  Fevers. — In  fevers  of  low  type  a 
crepitant  rale,  which  might  be  supposed  to  be  a  proof  of  beginning 
inflammation  of  the  lung,  is  often  heard  at  the  back  part  of  the 
chest.  The  sound  is  the  consequence  of  pulmonary  congestion. 
It  is  perceived  over  both  lungs ;  and  this,  taken  in  connection 
with  the  history  of  the  case,  and  with  the  rale  not  being  followed 
by  decided  shortness  of  breath  and  by  dulness  on  percussion  and 
blowing  respiration,  shows  that  it  is  not  dependent  on  inflamma- 
tion of  the  pulmonary  tissue.  It  is  necessary  to  be  aware  that 
these  fine  rales  may  occur  in  fevers  without  being  due  to  a  true 


310  MEDICAL    DIAGNOSIS. 

pneumonia ;  as  otherwise  the  patient  is  apt  to  be  treated  for  a 
disease  of  the  lung  which  has  no  existence. 

Hypostatic  Congestion. — Besides  the  lung  congestion  just  referred 
to  as  occurring  in  fevers,  we  have  other  causes  producing  a  marked 
congestion,  or  hypostatic  pneumonia.  We  find  it  in  enfeebled 
hearts,  in  those  whose  blood  is  impoverished  and  who  are  for  any 
length  of  time  bedridden,  and  in  instances  of  acute  rheumatism. 
In  the  dependent  portions  of  the  lungs  the  signs  of  congestion 
show  themselves  first;  and  they  are,  besides  the  signs  of  accelerated 
and  impeded  circulation  and  deficient  aeration  of  blood,  slight 
expectoration,  scarcely  any  fever,  varying  shortness  of  breath, 
somewhat  impaired  resonance  on  percussion  at  the  lower  part  of 
the  chest, — generally  more  over  the  right  than  over  the  left  lung, 
— feebleness  of  respiratory  murmur,  and  a  few  fine  and  coarse 
moist  rales. 

In  its  second  stage,  owing  to  the  cough  and  dyspnoea,  and  in 
part,  also,  to  some  similarity  in  the  physical  signs,  acute  pneu- 
monia may  be  confounded  with  pulmonary  apoplexy,  acute  pleu- 
risy, acute  phthisis,  and  acute  bronchitis. 

Pulmonary  Apoplexy. — An  effusion  of  blood  into  the  texture 
of  the  lung  is  generally,  although  by  no  means  invariably,  accom- 
panied by  external  hemorrhage  and  by  great  difficulty  of  breathing. 
Over  the  effused  blood  there  is  dulness  on  percussion,  and  the  ear 
hears  an  enfeebled  or  bronchial  respiration.  Around  the  seat  of 
the  mishap  it  encounters  moist  rales.  Now,  here  are  signs  bear- 
ing some  resemblance  to  those  of  pneumonia.  But  we  miss  from 
among  them  the  decided  fever.  AVe  find,  on  the  other  hand,  not 
blood  intimately  mixed  with  the  expectoration,  but  pure  blood, 
florid  or  sooty-looking,  almost  devoid  of  air,  in  not  large  amount, 
at  times  surrounded  with  muco-purulent  matter,  and  ordinarily 
voided  for  a  number  of  days.  On  close  scrutiny  a  grave  disease 
of  the  heart  is  generally  detected  to  explain  why  an  extravasation 
of  blood  into  the  pulmonary  structure  has  taken  place.  Then, 
as  recent  researches  have  demonstrated,  we  most  frequently  find 
the  branch  of  the  pulmonary  artery  leading  to  the  infarcted  part 
plugged  by  an  embolus,  which  has  been  formed  in  the  right  cavi- 
ties of  the  heart  or  been  washed  in  through  the  general  venous 
system,  and  most  commonly  affects  the  right  lung.  Again,  we 
have  more  pain  than  in  pneumonia,  and  the  dyspnoea  is  different. 


DISEASES    OF    THE    LUNGS.  311 

In  pneumonia  it  augments  up  to  the  height  of  the  malady.  In 
pulmonary  apoplexy  it  is  greatest,  and  it  is  very  great,  when  the 
blood  is  extravasated ;  after  that  it  declines.  Yet  the  two  affections 
often  coexist.  The  closure  of  the  vessel  produces  a  pneumonia 
from  embolism,  or  the  blood  acts  as  a  foreign  body,  and  around  it 
is  lighted  up  an  inflammation  of  the  lung-structure,  which  is  apt 
to  have  its  seat  in  the  posterior  part  of  the  lower  lobe  of  the  right 
lung;  further,  the  inflammation,  as  is  contended  for  by  Niemeyer 
with  regard  to  all  the  forms  of  pulmonary  hemorrhage,  may  be 
the  starting-point  of  caseous  degeneration  and  phthisis.  Pneu- 
monia from  embolism  may  be  also  caused  by  a  pyemic  condition, 
and  the  clots  may  have  their  origin  in  bedsores,  in  ulcers,  and 
in  various  forms  of  suppuration.  The  plugs  are  saturated  with 
ichor,  and  metastatic  abscesses  ordinarily  result.  The  symptoms 
are  the  same,  and  we  can  only  make  a  diagnosis  by  the  history; 
there  are  the  same  circumscribed  spots  of  consolidation,  and  the 
same  kind  of  pain,  which  is  also  often  found  to  be  associated  with 
a  localized  pleurisy,  sometimes  followed  by  effusion. 

Pulmonary  apoplexy  is  met  with  in  connection  with  other  than 
thoracic  affections.  Observations  by  Brown-Sequard  and  by 
Ollivier  have  proved  its  association  with  central  nervous  lesions, 
and  have  demonstrated  its  occurrence  on  the  same  side  as  the 
brain  lesion;*  which  is  not  the  case  with  reference  to  the  ordinary 
acute  pulmonary  diseases,  for  these  Rosenbachf  has  shown  to  be 
much  more  frequent  on  the  paralyzed  side  of  the  body,  and  there- 
fore, generally,  on  the  side  opposite  to  the  cerebral  mischief. 

Of  the  other  diseases  mentioned  which  resemble  pneumonia, 
the  distinguishing  points  need  not  be  here  fully  described.  Acute 
pleurisy  will  be  farther  on  more  particularly  studied.  With 
regard  to  acute  phthisis,  it  is  only  necessary  to  repeat  that  cases 
are  encountered,  apparently  of  pneumonia,  in  which,  after  the 
symptoms  of  acute  inflammation  of  the  lung  pass  off,  those  of 
phthisis  come  into  the  foreground.  With  reference  to  acute 
bronchitis,  I  shall  merely  recall  that  the  dyspnoea  is  not  so  great, 
and  that  no  percussion  dulness  is  yielded  by  an  inflamed  bronchial 
membrane. 

Percussion  is  thus  of  signal  value  in  the  diagnosis  of  pneumo- 

*  Arch.  Gen.  de  Med.,  Aug.  1873.  f  Centralblatt,  No.  16,  1879. 


312  MEDICAL   DIAGNOSIS. 

nia.  In  fact,  when  bronchitis  complicates  pneumonia,  and  loud, 
dry  rales  take  the  place  of  the  blowing  respiration,  it  is  our  only 
trustworthy  guide.  A  single  tap  on  the  chest  which  elicits  an 
absolutely  dull  sound  tells  the  difference  between  pure  bronchitis 
and  the  inflammation  of  the  bronchial  mucous  membrane  which 
accompanies  inflammation  of  the  parenchymatous  structure  of  the 
lung. 

The  form  of  pneumonia  most  liable  to  be  mistaken  for  bron- 
chitis is  the  pneumonia  of  childhood  or  of  old  age,  the  lobular  or 
catarrhal  pneumonia.  It  would  be  obligatory  here  to  dwell  on 
its  special  characters,  its  diffusion,  its  relations  to  capillary  bron- 
chitis and  to  collapse  of  the  lung,  were  it  not  that,  in  treating 
of  these  disorders,  it  has  been  described  with  them.  But,  as  the 
disease  may  also  occur  in  adults,  and  has  a  special  significance 
with  reference  to  consumption,  a  few  words  more  will  not  be  out 
of  place. 

Catarrhal  Pneumonia. — It  supervenes  upon  catarrhal  bronchi- 
tis, except  in  instances  in  which  it  arises  from  inhaling  irritating 
gases.  The  bronchial  attack  is  usually  severe,  but  it  may  be  so 
slight  as  to  be  readily  overlooked.  The  spread  of  the  disease 
to  the  lung-texture  is  attended  with  rapid  rise  of  temperature. 
When  the  disorder  attacks  adults,  it  is  apt  to  seize  upon  those 
debilitated  by  previous  disease ;  it  much  more  commonly  affects 
the  upper  lobes  than  does  ordinary  sthenic  pneumonia,  and  is 
generally  bilateral.  As  the  broncho-pneumonia  merely  solidifies 
lobules,  the  signs  of  marked  consolidation  are  wanting,  or  are 
perceptible  over  only  a  small  space.  Crepitation  is  not  common, 
but  small  moist  rales  are ;  bronchial  breathing  and  increased 
fremitus  show  only  over  limited  points;  and  the  sputum  is  not 
rusty  and  viscid,  but  catarrhal.  Catarrhal  pneumonia  is  apt  to 
pursue  a  much  slower  course  than  croupous  pneumonia,  and  gen- 
erally disappears  only  very  gradually.  The  consolidation  and  the 
febrile  phenomena  may  continue  stationary  for  weeks  and  then 
gradually  disappear.  But,  on  the  other  hand,  caseous  degenera- 
tion and  breaking  down  of  the  lung-texture  may  follow,  or  ex- 
tended tubercular  infiltration  may  take  place.  Phthisis,  in  truth, 
is  in  adults  a  not  uncommon  termination ;  in  children,  too,  this 
may  happen,  or  rachitis  develop  itself,  or  an  ill-defined  but  per- 
sistent cachexia,  and  a  great  tendency  to  catch  cold. 


DISEASES    OF    THE    EUXGS.  313 

There  are  further  two  other  forms  of  inflammation  of  the  lung 
which  have  not  been  elsewhere  considered,  and  which,  as  they 
present  somewhat  peculiar  symptoms,  require  to  be  explained. 
They  are  typhoid  pneumonia  and  bilious  pneumonia. 

Typhoid  Pneumonia. — Inflammation  of  the  lung  may  be  from 
its  onset  attended  with  extreme  prostration.  This  form  of  the 
disease  has  been  made  a  matter  of  warm  controversy,  both  as  to 
the  symptoms  which  characterize  it  and  as  to  the  relation  it  bears 
to  other  varieties  of  the  malady.  Now,  any  one  who  reads  the 
dissimilar  descriptions  given  of  it  will  become  convinced  that 
under  the  term  typhoid  pneumonia  the  most  various  disorders 
have  been  ranged  together.  On  the  one  hand,  it  has  been 
applied  exclusively  to  the  inflammation  of  the  lung  which  may 
complicate  typhus  or  typhoid  fever;  on  the  other  hand,  it  has 
been  made  to  include  an  idiopathic  fever  in  which  the  affection 
of  the  respiratory  organs  is  occasionally  wanting.  To  neither  of 
these  diseases  ought  to  belong  the  name  typhoid  pneumonia,  since 
in  both  the  inflammation  of  the  lung  is  but  an  incidental,  although 
a  grave,  accompaniment. 

Typhoid  pneumonia  is  pneumonia  with  symptoms  of  a  typhoid 
type,  and  marked  by  rapid  failure  of  the  vital  powers.  The  in- 
flammation of  the  lung  arising  in  the  course  of  typhus  or  typhoid 
fever  will  of  course  be  apt  to  present  this  character :  but  the 
malady  is  also  noticed  as  a  consequence  of  phlebitis;  as  super- 
vening in  cases  of  erysipelas,  of  Bright's  disease,  and  of  delirium 
tremens ;  or  as  the  sole  apparent  affection.  It  happens  not  unfre- 
quently  in  epidemics,  and  is  very  often  observed  among  negroes. 
Its  ravages  on  the  plantations  of  South  Carolina  and  Georgia  are 
sometimes  frightful.  It  is,  also,  very  fatal  among  troops  in  the 
field,  serving  in  unhealthy  localities  and  placed  under  unfavorable 
hygienic  conditions. 

The  physical  signs  are  those  of  the  sthenic  form  of  the  disease, 
except,  perhaps,  that  the  crepitant  rale  is  less  frequent.  Most  of 
the  same  symptoms,  too,  show  themselves :  cough,  short  breathing, 
and  pain  in  the  chest.  All  of  these  may  be  very  marked,  or  so 
trifling  as  hardly  to  direct  attention  to  the  lungs.  There  is,  how- 
ever, one  symptom  characteristic  and  constant,  and  but  one,  and 
that  is  the  great  tendency  to  sinking.  As  regards  the  expectora- 
tion, it  may  be  rusty-colored ;  yet  occasionally,  even  in  the  early 


314  MEDICAL    DIAGNOSIS. 

stages  of  the  complaint,  it  consists  of  pure  blood.  The  pulse  is 
always  quick,  but  weak.  Dark  sorties  often  collect  on  the  teeth 
and  gums,  as  they  do  in  typhoid  fever.  Pain  is  absent  iu  some 
cases,  and  extremely  acute  and  of  a  radiating  character  in  others. 
Concerning  delirium,  we  know  that  it  is  much  more  common  than 
it  is  in  the  sthenic  variety  of  pulmonary  inflammation,  except  this 
affect  the  apex  in  children.  Some  authors  mention  an  eruption. 
It  is,  however,  questionable  whether  the  cases  which  came  under 
their  notice  were  not  typhus  or  typhoid  fever,  in  the  course  of 
which  pneumonia  appeared.  The  flush  on  the  face  in  the  low  type 
of  the  malady  under  consideration  is  usually  of  a  dusky  hue,  but 
not  invariably :  a  pink-colored  blush,  extending  sometimes  all 
over  the  body,  seems  to  have  specially  attracted  the  attention 
of  observers.  The  disease  is  always  dangerous,  and,  as  Stokes* 
tells  of  the  typhoid  pneumonia  he  met  with  in  Dublin,  although 
generally  developed  with  rapidity,  resolution  is  extremely  slow, 
Chronic  hepatization,  with  or  without  a  low  hectic  fever,  or  a 
lurking  congestion,  may  continue  for  weeks. 

The  symptoms  of  typhoid  pneumonia  are  at  times  strangely 
mixed  up  with  those  produced  by  other  conditions.  In  many 
districts,  in  which  the  complaint  is  prevalent,  it  bears  the  distinct 
impress  of  malaria.  Again,  articular  symptoms  seem  to  predomi- 
nate in  some  regions  of  country,  and  in  some  epidemics.  Gibbesf 
speaks  of  an  acute  pain  in  the  back  part  of  the  eye,  in  the  ears,  or 
in  the  side  of  the  neck,  attended  with  stiffness  of  the  muscles ;  and 
of  a  swelling  of  the  tonsils,  and  of  the  submaxillary  and  sublin- 
gual glands,  which  he  states  to  be  of  evil  augury.  Dickson,^ 
drawing  his  description  of  the  disease  from  a  large  number  of 
cases  observed  in  and  around  Charleston,  portrays  several  forms, 
the  most  common  of  which  exhibits  a  respiration  hurried,  uneasy, 
and  irregular;  deep  and  heavy  sighing;  a  feeling  of  weight  at 
the  precordial  region,  with  nausea,  gastric  distress,  and  vomiting; 
and  a  tongue  clean,  but  red.  Delirium  is  present  from  the  begin- 
ning, and  does  not  subside  until  recovery  takes  place.  The  dura- 
tion of  such  attacks  averages  from  six  to  ten  days.  In  another 
form,  there  are  at  the  onset  great  gastric  oppression  and  vomiting, 

*  Diseases  of  the  Chest.  f  Amer.  Journ.  of  Med.  Sciences,  1842. 

J  Elements  of  Medicine. 


DISEASES    OF    THE    LUNGS.  315 

and  signs  of  vascular  excitement.  But  muscular  prostration  and 
debility  soon  happen ;  and  lividity  of  the  countenance,  petechial 
spots,  and  coma  are  symptoms  which  usher  in  dissolution. 

Bilious  Pneumonia. — Jaundice  and  other  indications  of  hepatic 
and  gastric  derangement  are  not  usual  in  ordinary  sthenic  pneu- 
monia. They  may  be  occasionally  caused  by  the  inflammation 
spreading  to  the  liver,  or  may  be  noticed  where  no  evidence  of  such 
an  occurrence  exists.  But  in  the  pneumonia  so  general  in  spring 
and  autumn  in  the  miasmatic  regions  of  some  of  the  Southern 
and  Western  States  of  this  country,  these  symptoms  are  common, 
and  mark  a  special  type  of  the  disease,  known  as  malarial  pneu- 
monia, bilious  pneumonia,  or  by  the  familiar  name  of  "  bilious 
pleurisy." 

This  form  of  inflammation  of  the  lung  is  simply  pneumonia, 
sthenic  or  asthenic,  on  whose  features  the  stamp  of  malaria  is  im- 
printed. The  chill  with  which  it  begins  is  usually  protracted,  and 
is  followed  by  pain  in  the  side,  by  fever,  by  hurried  breathing,  by 
cough,  and  by  tenacious,  rusty-colored  expectoration.  The  pain 
in  the  side,  which  depends  upon  accompanying  pleurisy,  is  sharp 
and  severe,  and  renders  the  respiration  irregular.  The  sputum  is 
at  times  rusty-colored,  while  at  others  a  frothy  and  bloody  serum 
or  pure  blood  is  expectorated.  The  fever  shows  the  type  of  the 
disease.  It  is  much  more  paroxysmal  than  in  the  other  varieties 
of  the  malady.  This  peculiarity,  and  the  obvious  symptoms  of 
hepatic  and  gastric  disorder,  are  indeed  the  only  absolutely  dis- 
tinguishing traits  of  bilious  pneumonia.  The  febrile  exacerbations 
are  stated  by  Dr.  Manson,  a  physician  of  North  Carolina,  to  be 
preceded,  during  the  morning  hours,  by  an  insensible  chill, — a 
coolness  of  the  ends  of  the  nose,  fingers,  and  toes,  which,  in  grave 
cases,  extends  over  the  entire  extremities.*  The  same  writer 
dwells  on  the  irritability  of  the  intestinal  canal,  and  the  occurrence 
of  greenish-black,  viscid  and  inodorous  stools.  This,  and  the 
diminution  of  the  dyspnoea,  diaphoresis,  and  a  copious  secretion 
of  urine,  point  to  a  favorable  issue  of  the  disease.     On  the  other 

*  Virginia  Med.  Journ.,  Sept.  and  Oct.  1857.  See  also  an  excellent  essay 
on  the  subject  by  W.  F.  Howard,  North  Carolina  Med.  Journ.,  Feb.  1859; 
Eamsay,  Charleston  Med.  Journ.,  vol.  vi.  ;  Merrill,  New  Orleans  Med.  and 
Surg.  Journ.,  July,  1851  ;  Drake  on  the  Diseases  of  the  Interior  Valley  of 
North  America;  and  Morehead,  "  Diseases  of  India." 


316  MEDICAL   DIAGNOSIS. 

hand,  it  may  terminate  fatally  with  symptoms  indicative  of  great 
prostration. 

The  physical  signs  are  those  of  ordinary  acute  pneumonia. 
Bronchial  breathing  and  bronchophony  are  said  to  be  more  often 
absent,  or  to  appear  and  disappear  rapidly.  It  is  certain,  if  this 
be  true,  that  in  these  instances  the  malady  could  not  have  been 
inflammation,  but  was  more  probably  a  collapse  of  the  pulmonary 
tissue.  Any  one,  indeed,  who  compares  the  various  statements 
made  with  reference  to  the  disease,  must  have  been  struck  with 
the  fact  that  cases  of  congestive  fever  in  which  the  lungs  have 
become  simply  engorged,  or  perhaps  collapsed,  and  cases  of  in- 
flammation of  the  lung  arising  in  the  course  of  remittent  fevers, 
are  included  in  the  same  description  with  true  cases  of  idiopathic 
bilious  pneumonia. 

The  nature  of  an  inflammation  of  the  lung  bearing  so  decidedly 
the  livery  of  malaria  has  given  rise  to  warm  controversies.  Re- 
garded by  some  as  nothing  more  than  a  special  form  of  remittent 
or  intermittent  fever,  in  which  the  lungs  are  made  to  bear  the 
burden  of  the  disease,  it  is  by  others  held  to  be  simply  a  variety 
of  pneumonia,  occasioned  by  the  ordinary  causes  of  this  affection, 
but  owing  its  peculiar  symptoms  to  its  happening  in  those  in 
whose  systems  the  poison  of  malaria  has  been  slumbering. 

Acute  Pleurisy. — Acute  pleurisy  has  been  so  often  inci- 
dentally mentioned,  that  a  description  of  its  main  points  will 
here  suffice.  The  first  effect  of  the  inflammation  is  to  redden  the 
pleural  membrane;  an  exudation  of  a  soft,  grayish,  and  easily- 
detached  lymph  then  takes  place.  This  constitutes  the  first  or 
dry  stage  of  the  disease ;  and  if  the  two  inflamed  surfaces  unite, 
the  disorder  does  not  pass  beyond  this  stage.  Often,  however, 
along  with  the  exudation  of  lymph  occurs  an  effusion  of  serum, 
which  produces  a  special  train  of  phenomena,  and  gives  rise  to 
the  second  stage,  or  that  of  liquid  effusion. 

The  physical  signs  of  the  dry  stage  are  impaired  movement  of 
the  chest,  a  feebler  respiration,  and  a  friction  sound  of  varying 
extent  and  intensity.  The  first  two  signs  are  caused  by  the  patient 
instinctively  recoiling  from  expanding  the  lung,  because  of  the 
pain  it  occasions.  The  mechanism  of  the  friction  sound,  its 
nature,  its  superficial  character  and  want  of  uniformity,  have  been 
pointed  out  in  a  previous  part  of  this  chapter.     In  the  stage  of 


DISEASES    OF    THE    LUNGS. 


317 


effusion  the  physical  signs  differ  somewhat  according  to  the 
amount  of  fluid  the  pleural  cavity  contains.  A  moderate  quantity 
of  liquid  only  constricts  the  lung-texture,  and  leaves  the  bronchial 
tubes   intact;   a   large   accumulation  compresses   everything;   it 


Fig 


Friction  sound. 


Koughening  of  the  pleura  from  inflammation  ;  a  small  amount 
of  fluid  has  begun  to  collect. 

drives  all  air  out  of  the  lung,  pushes  it  into  a  small  space  against 
the  vertebral  column,  and  displaces  the  liver  or  heart.  Wherever 
the  fluid  accumulates  there  is  dulness  on  percussion.  When  the 
patient  is  in  the  erect  posture,  the  flat  sound  on  striking  the  chest 
and  the  sense  of  resistance  to  the  finger  are  marked  at  the  lower 
part  of  the  thorax,  since  the  fluid  naturally  settles  there.  The 
line  of  dulness,  is,  however,  not  the  same  in  front  as  it  is  behind. 
It  is  generally  much  higher  behind,  and  alters,  of  course,  with  the 
changing  quantity  of  effusion,  and  somewhat  with  the  position  of 
the  patient.*     When  he  lies  upon  his  face,  the  fluid  gravitates,  if 

*  Dr.  Calvin  Ellis  has  described  a  peculiar  curve  of  the  percussion  line, 
which,  from  its  resemblance  to  the  letter  S,  has  been  named  by  Dr.  Garland 
"the  letter  S  curve"  of  pleurisy,  and  is  regarded  as  characteristic  (Pneu- 
mono-Dynamics,  1878,  and  New  York  Medical  Journal,  Nov.  1879). 


318 


MEDICAL,    DIAGNOSIS. 


not  circumscribed  by  adhesions,  toward  the  anterior  chest-walls, 
and  the  percussion  dulness  posteriorly  becomes  far  less  perceptible. 
Where  the  effusion  is  at  all  extensive,  the  intercostal  spaces  are 
widened  and  their  depressions  effaced.  The  side  appears  to  the 
eye  distended,  fluctuation  may  be  perceived,  and,  owing  to  the 
absolute  compression  of  the  lung,  no  sound  is  heard  over  the  chest 

Fig.  28. 


Great  dulness 

Absent  voice 

Absent  respiration... 
Absent  fremitus 


Examination  of  the  posterior  portion  of  the  chest  while  a  large  effusion  is 
occupying  the  left  pleural  cavity. 


when  the  patient  breathes,  or  speaks,  or  coughs.  In  more  moder- 
ate collections  of  fluid,  the  cessation  of  sound  is  not  so  absolute. 
There  is  an  ill-defined,  deep-seated  respiration,  and  the  voice 
reaches  the  ear  with  tolerable  distinctness,  and  occasionally  with  a 
peculiar  bleating  resonance  attending  it.  But,  as  large  collections 
of  fluid  are  more  common  than  small  ones,  the  former  set  of  phe- 
nomena are,  at  the  height  of  the  disease,  more  frequent  than  the 
latter. 

Above  the  liquid  there  is  mostly  increased  resonance  on  per- 


DISEASES    OF    THE    LUNGS.  319 

cussion,  or  a  tympanitic  sound.  Various  explanations  have  been 
given  of  this  phenomenon.  It  has  been  attributed  to  the  complete 
compression  of  the  lung :  it  has  been  thought  to  be  due  to  its 
slight  condensation.  AVhatever  be  the  true  explanation,  the  fact 
of  its  occurrence  is  undeniable.  This  tympanitic  sound  is  more 
manifest  at  the  upper  part  of  the  chest  in  front;  it  may,  indeed, 
sometimes  be  found  in  front  when  it  does  not  exist  at  all  behind. 
In  many  cases  the  sound  has  a  decidedly  amphoric,  in  others  a 
cracked-metal  character.  When  the  ear  is  applied  above  the  line 
of  percussion  dulness,  it  recognizes  occasionally  a  friction  sound  ; 
and  near  the  spinal  column  posteriorly,  where  the  compressed  lung 
lies,  it  perceives  almost  invariably  distinct  bronchial  respiration 
and  bronchophony. 

When  the  fluid  begins  to  be  absorbed,  the  voice  becomes  more 
audible  over  the  seat  of  the  effusion,  the  vocal  vibrations  may  be 
felt  by  the  fingers,  and  the  respiration  is  again  heard.  But  for  a 
long  time  it  continues  enfeebled,  and  its  character  is  indetermi- 
nate; it  is  neither  vesicular  nor  purely  bronchial.  As  more  and 
more  of  the  fluid  disappears,  the  voice  becomes  more  and  more  dis- 
tinct ;  a  friction  sound  finally  shows  that  the  roughened  surfaces 
have  come  in  contact;  and  the  dulness  on  percussion  is  replaced 
by  a  far  clearer  sound.  False  membranes  now  unite  the  two 
pleura?;  the  intercostal  spaces  resume  their  normal  shape;  and 
the  chest  is  either  restored  to  its  natural  size,  or  is  left  perma- 
nently somewhat  contracted.  The  bronchial  breathing  near  the 
vertebral  column  persists  for  a  long  time,  since  a  lung  that  has 
been  compressed  unfolds  but  slowly. 

Such  are  the  different  physical  signs  which  inflammation  of 
the  pleura  exhibits.  They  have  been  discussed  first,  and  at  some 
length,  because  I  wished  to  make  it  apparent  that  these  signs  are 
the  most  important  elements  in  the  diagnosis.  The  symptoms, 
indeed,  often  hardly  attract  attention ;  and  if  we  trusted  to  them, 
we  should  be  constantly  groping  in  the  dark.  Pleurisy  mostly 
begins  with  a  chill,  followed  by  fever  and  by  a  dry,  irritating 
cough.  The  most  distinctive,  though  not  a  constant,  symptom  of 
the  first  stage  is  the  sharp,  acute  pain,  the  "stitch  in  the  side." 
It  is  commonly  felt  under  the  nipple  or  in  the  axilla,  and  is  some- 
what increased  on  pressure.  Its  seat  by  no  means  always  corre- 
sponds to  the  seat  of  the  friction  sound.     As  the  effusion  takes 


320  MEDICAL   DIAGNOSIS. 

place  the  pain  disappears,  dyspnoea  becomes  evident,  and  the  pa- 
tient ordinarily  lies  on  the  affected  side.  The  febrile  symptoms 
and  dry  cough  continue;  yet  neither  is  marked,  and  both  dis- 
appear long  before  the  fluid  is  entirely  absorbed. 

Pleurisy  may  be  idiopathic,  or  it  may  be  an  attendant  upon 
other  diseases,  such  as  affections  of  the  lungs,  measles,  scarlatina, 
typhoid  and  typhus  fevers.  It  may  also  be  caused  by  wounds  of 
the  thoracic  walls,  by  Bright's  disease,  rheumatism,  gout,  diph- 
theria, pysemia,  and  other  morbid  states. 

The  malady  with  which  acute  idiopathic  pleurisy  is  most  likely 
to  be  confounded  is  acute  pneumonia.  Both  are  affections  occa- 
sioning dyspnoea ;  both  are,  in  the  majority  of  cases,  one-sided ; 
both  present,  in  their  most  advanced  stages,  dulness  on  percus- 
sion. But  the  dulness  in  the  latter  disease  is  far  less  absolute 
than  in  the  former ;  nor  do  we,  save  in  very  rare  instances,  meet 
with  a  tympanitic  or  amphoric  percussion  sound  in  pneumonia, 
while  in  pleurisy,  as  we  have  just  seen,  it  is  far  from  unusual 
above  the  level  of  the  fluid.  In  those  few  cases  in  which  an 
amphoric  or  a  tympanitic  sound  is  perceived  in  pneumonia, — a 
condition  of  things,  it  may  be  mentioned  in  passing,  which  has 
not  as  yet  received  a  satisfactory  explanation, — the  peculiar  tone 
is  most  obvious  over  the  consolidated  tissue. 

The  other  physical  signs  of  the  two  diseases  show  still  less 
similitude.  The  absence  of  respiration,  of  vocal  resonance,  and 
of  thrill,  is  in  striking  contrast  with  the  loud  blowing  respiration, 
the  strong  chest-voice,  and  the  increased  vocal  thrill  of  pneu- 
monia. There  are,  however,  exceptional  cases  of  pleuritic  effusion, 
in  which  bronchial  breathing  is  heard  all  over  one  side  of  the 
chest.  Especially  does  this  happen  if  pneumonic  consolidation 
accompany  the  effusion;  but  even  in  simple  compression  of  the 
lung,  and  where  the  collection  of  liquid  is  not  extensive,  bronchial 
respiration  may  be  perceived.  The  difficulty  of  distinguishing 
from  pneumonia  such  cases  of  pleurisy,  in  which  probably  the 
lung-tissue  is  compressed  around  the  bronchial  tubes  but  these 
are  not  encroached  upon,  is  great.  As  aids  in  diagnosis,  we  seek 
for  the  dilatation  of  the  chest;  we  note  the  peculiarities  of  the 
breathing,  which,  although  blowing,  is  mostly  fainter  than,  and 
unlike,  the  high-pitched,  brazen  respiration  of  pneumonia;  we 
find  that  the  percussion  dulness  over  the  upper  part  and  where 


DISEASES    OF    THE    LUXGS. 


321 


the  bronchial  respiration  is  most  distinct  is  not  very  great,  and, 
especially,  that  it  disappears  on  respiratory  percussion ;  we  observe 
that  the  voice  is  less  strong  and  ringing,  and  has,  perhaps,  a  bleat- 
ing tone ;  and  we  take  into  account  the  appearance  of  the  sputum 
and  the  character  of  the  fever.  But,  leaving  these  cases  out  of 
consideration,  the  diagnosis  between  the  two  affections  is  easy. 
It  may  be  thus  summed  up : 


Pleurisy. 

Sharp  pain  ;  friction  sound  ;  dry 
cough ;  impaired  chest-motion. 

In  stage  of  effusion,  obliteration  of 
the  intercostal  spaces ;  enlarge- 
ment of  the  side  ;  displacement  of 
several  viscera. 

In  the  large  majority  of  cases,  dul- 
ness,  with  enfeebled  or  absent  res- 
piration, voice,  and  fremitus. 

Decubitus  is  often  on  the  affected 
side. 

Sputa  frothy ;  rarely  any  rales  in  the 
chest. 

Febrile  symptoms  usually  slight. 
Temperature    record    irregular,    and 
not  characteristic  ;  rarely  high. 


Pnetjmoxia. 

Dull  pain  ;  crepitant  rale  ;  cough,  fol- 
lowed by  expectoration. 

In  stage  of  hepatization,  none  of 
these  sifirns  are  manifest. 


Dulness,  with  marked  bronchial  res- 
piration ;  distinct  thoracic  voice ; 
increased  vocal  fremitus. 

Decubitus  not  peculiar  ;  sometimes  on 
the  sound  side. 

Sputa  rusty-colored;  rales  from  ac- 
companying bronchial  inflamma- 
tion common. 

Febrile  symptoms  severe. 

Temperature  record  much  more  char- 

-  acteristic.  Temperature  rises  rap- 
idly soon  after  onset,  then  is  contin- 
uous with  marked  evening  exacer- 
bations, from  two  to  three  degrees, 
and  morning  remissions.  Often 
reaches  105°.  May  show  sudden 
elevations  and  striking  falls  in  the 
whole  course  of  the  fever.  Toward 
end  of  disease  generally  rapid  de- 
fervescence. High  temperature  not 
uncommon,  especially  in  pneumo- 
nia of  upper  lobe. 

In  the  first  stage  of  pleurisy  the  pain  might  cause  the  disease  to 
be  confounded  with  pleurodynia  or  intercostal  neuralgia.  In  all 
three  pain  is  the  prominent  symptom.  Let  us  see  how  it  differs 
in  each: 

Pleurodynia. — Pleurodynia  is  described  as  a  form  of  muscular 
rheumatism.  But  frequently  it  is  myalgia,  or  pleurisy  which 
does  not  pass  beyond  the  dry  stage.     Of  this  nature  are  most  of 

21 


322  MEDICAL   DIAGNOSIS. 

the  fugitive  chest-pains  from  which  phthisical  patients  suffer. 
Yet  there  are  cases  in  which  no  signs  whatever  of  pleurisy  exist, 
but  which  are  attended  with  as  much  pain  as  pleurisy.  The  pain 
of  pleurodynia  is,  indeed,  often  excessively  severe;  the  patient 
refrains  from  deep  breathing,  since  every  motion  of  his  chest, 
voluntary  or  involuntary,  increases  his  suffering.  The  pain  is 
augmented  by  movements  of  the  arm  and  by  pressure,  and  is 
generally  associated  with  tenderness.  Pleurodynia  shares  with 
pleurisy  the  feeble  respiration  and  the  want  of  action  of  the  affected 
side.  It  differs  from  it  by  the  absence  of  friction  sound  and  of 
fever;  by  the  shifting  tendency  of  the  pain;  by  its  attacking  often 
both  sides ;  and  by  the  greater  tenderness  of  the  chest- walls. 

Intercostal  Neuralgia. — In  anaemic  women  and  in  consumptives 
acute  thoracic  pain  is  not  uncommonly  the  result  of  an  intercostal 
neuralgia.  The  same  want  of  expansion  of  the  chest  and  the  same 
enfeebled  breathing  as  in  pleurodynia  are  here  noted,  also  the  same 
absence  of  fever  and  of  pleural  friction.  The  distinguishing  marks 
of  intercostal  neuralgia  are:  its  intermittent  character;  its  frequent 
association  with  uterine  disturbance,  especially  with  leucorrhoea, 
and  the  limitation  of  the  tenderness  to  special  points  in  the  course 
of  the  affected  nerve.  Valleix  has  drawn  attention  to  three  pain- 
ful spots  which  are  tender  to  the  touch :  one  at  the  exit  of  the 
nerve  from  the  spinal  column,  the  second,  in  the  axillary  region, 
and  the  third,  near  the  sternum  or  in  the  epigastric  region.  It  is 
on  the  left  side  that  we  are  most  apt  to  find  intercostal  neuralgia, 
and  between  the  sixth  and  ninth  ribs  that  the  painful  places  are 
usually  detected.  % 

Pain  occurs  also  in  diseases  affecting  the  lung-texture.  There  is 
pain  of  a  dull  nature  in  pneumonia,  of  a  more  severe  character  in 
cancer.  But  the  pain  is  so  dissimilar,  and  the  coexisting  symptoms 
are  so  unlike,  that  the  error  of  confounding  these  maladies  with 
pleurisy,  on  account  of  the  pain,  is  not  likely  to  be  committed. 

Diseases  presenting  Dilatation  of  the  Chest,  Displacement  of 
the  Liver  or  Heart,  and  Dyspnosa. 

A  group  of  diseases  may  here  be  studied,  all  of  which  occasion 
more  or  less  dilatation  and  prominence  of  the  chest,  and  all  of 
which  are  attended  with  decided  shortness  of  breath.     In  bron- 


DISEASES    OF    THE    LTJXGS.  323 

chitis  and  pneumonia  a  slight  increase  in  the  diameters  of  the  chest 
may  take  place ;  but  it  is  not  a  sign  of  any  diagnostic  importance. 
In  the  recognition  of  emphysema,  pneumothorax,  and  pleuritic 
effusions,  the  dilatation  of  the  thorax  forms  one  of  the  main 
elements ;  moreover,  it  is  often  combined  with  marked  dyspnoea 
and  with  displacement  of  the  liver  or  heart.  These  affections, 
then,  may  be  examined  in  the  same  connection,  and  compared  with 
one  another,  and  incidentally  with  several  less  common  diseases 
which  present  similar  manifestations. 

The  history  and  signs  of  emphysema  were  given  when  treating 
of  the  diseases  accompanied  by  clearness  on  percussion.  It  was 
then  mentioned  that  in  many  instances  the  prominence  of  the 
chest  was  circumscribed.  Such  cases  cannot  be  mistaken :  the 
bulging  is  too  limited.  But  when  the  emphysema  is  more  gen- 
eral, and  an  entire  side  of  the  chest  or  the  whole  chest  becomes 
dilated,  or  when  the  inflated  lung  displaces  the  liver  or  heart,  the 
affection  comes  into  the  group  under  consideration.  A  patient 
seeks  advice  for  shortness  of  breath.  His  chest  is  inspected,  and 
looks  enlarged.  The  physical  signs  prove  that  the  disease  is  not 
one  of  the  heart.  What,  then,  is  it?  Is  it  an  effusion  into  the 
pleura  ?  is  it  pneumothorax  ?  is  it  emphysema  ?  A  tap  on  the 
chest  goes  far  toward  showing  whether  it  be  the  former.  If  the 
sound  rendered  be  resonant,  it  is  not  liquid  in  the  chest  that  is 
producing  the  disturbance :  the  disorder  is  either  pneumothorax 
or  emphysema. 

Pneumothorax. — Of  all  thoracic  maladies,  pneumothorax  is 
the  one  the  similarity  of  which  to  extensive  dilatation  of  the  air- 
cells  is  the  greatest.  In  both,  the  large  quantity  of  air  occasions 
increased  clearness  on  percussion ;  in  both,  there  is  considerable 
and  persistent  difficulty  of  breathing ;  in  both,  the  distention  of 
the  chest  and  the  displacement  of  organs  may  be  obvious.  The 
symptoms  and  signs  are,  however,  in  pneumothorax,  associated 
with  different  conditions!  Pneumothorax  is  an  accumulation  of 
air  in  the  pleural  cavity,  but  it  is  something  more :  the  entrance 
of  air  is  soon  followed  by  the  effusion  of  liquid. 

Air  is  let  into  the  cavity  of  the  chest  by  the  pleura  being 
perforated  by  wounds,  or,  as  is  more  common,  by  its  partial 
destruction  consequent  upon  disease  of  the  lung.  It  is  in  this 
way  that  pneumothorax  originates   in  the  course  of  tubercular 


324  MEDICAL   DIAGNOSIS. 

softening,  of  gangrene,  of  pneumonia,  or  from  the  bursting  of  a 
distended  air-vesicle  or  of  a  dilated  bronchial  tube.*  In  the  large 
majority  of  instances  it  occurs  in  tubercular  patients. 

When  air  passes  from  the  lung  into  the  pleura,  it  usually  hap- 
pens during  a  paroxysm  of  coughing.  The  pain  which  ensues 
is  most  intense;  and  the  frightful,  suddenly  developed  dyspnoea, 
the  anxious  expression  of  face,  soon  show  how  seriously  the  respi- 
ration is  interfered  with.  If  death  do  not  take  place,  symptoms 
of  pleurisy  with  effusion  manifest  themselves ;  and,  as  in  pleurisy, 
the  patient  lies  ordinarily,  but  not  invariably,  on  the  aifected  side. 
Saussier,t  in  analyzing  the  position  of  fifty-six  patients,  notes  that 
twenty-eight  lay  on  the  affected  side,  nine  on  the  opposite  side, 
and  nineteen  in  various  postures. 

The  distinctive  marks  of  pneumothorax  are  furnished  by  its 
physical  signs.  The  ingress  of  air  into  the  pleural  cavity  widens 
the  chest,  effaces  the  depression  of  the  intercostal  spaces,  and 
occasions  an  extremely  clear,  or,  more  correctly  speaking,  a  tym- 
panitic, sound  on  percussion.  The  air  prevents  the  lung  from 
expanding :  hence  there  is  an  enfeebled  or  absent  respiration, 
except  near  the  spinal  column  where  the  compressed  organ  lies, 
and  where  the  breathing  is  bronchial.  The  hand,  if  laid  on  any 
other  portion  of  the  chest,  feels,  when  the  patient  speaks,  no  thrill, 
and  no  vocal  vibration  is  detected  by  the  ear.  When  the  perfora- 
tion has  not  closed,  and  the  air  rushes  into  the  artificial  cavity 
produced  by  the  separation  of  the  two  surfaces  of  the  pleura,  the 
respiration  is  amphoric,  or  it,  the  voice,  and  the  rales  are  all 
accompanied  by  a  distinct  metallic  ring;  respiratory  percussion, 
too,  changes  the  sound  elicited,  rendering  it  duller.  Drops  of  fluid 
falling  into  the  cavity,  or  the  bursting  of  bubbles  on  the  surface 
of  the  liquid  in  the  pleura,  are  also  echoed  to  the  ear  with  a 
metallic  sound,  and  are  often  heard  as  a  silvery  tinkle. 

The  presence  of  the  fluid  iu  the  pleural  cavity  gives  rise  to  a 
dull  sound  on  percussion  at  the  lower  part  of  the  chest,  and  to  a 
splash,  perceptible  to  the  ear  and  to  the  finger,  when  the  thorax  is 
suddenly  shaken.  This  continues  until  the  effusion  increases,  and 
until  the  opening  in  the  membrane  closes,  the  air  disappears,  and 


*  Case  recorded  by  Taylor,  Prov.  Med.  Journal,  vol.  i.,  1S42. 
•j-  Eeclierehes  sur  le  Pneumothorax,  Paris,  1841. 


DISEASES    OF    THE    LUNGS. 


325 


the  case  resolves  itself  into  one  of  chronic  pleurisy, — the  most 
favorable  termination  of  pneumothorax. 

Now  let  us  compare  the  physical  signs  with  those  produced  by 
emphysema.  The  sound  on  percussion  in  both  is  very  clear,  or  is 
tympanitic:  more  so,  however,  in  pneumothorax,  which,  in  addi- 
tion, exhibits  dulness  at  the  lower  part  of  the  chest.     The  respira- 


Fig.  29. 


Physical  signs  in  pneumothorax  on  the  right  side.  The  heart  is  observed  to  lie  dis- 
placed toward  the  left,  as  actually  happened  in  the  case  from  which  the  outline  was 
taken.  The  percussion  resonance  on  the  right  side  was  tympanitic,  extending  some- 
what over  the  left  margin  of  the  sternum;  the  fremitus  was  annulled;  the  voice 
metallic. 

tion  in  both  is  feeble.  But  it  is  feebler  in  pneumothorax,  and  not 
accompanied  by  a  long,  laborious  expiration ;  besides,  it  is  often 
amphoric,  and  attended  with  metallic  voice  and  tinkling, — phe- 
nomena which  dilated  air-cells  cannot  occasion.  Moreover,  there 
can  be  no  splashing  sound  in  emphysema ;  on  the  other  hand,  the 
displacement  of  the  heart  is  generally  much  greater  in  pneumo- 
thorax, and  the  dilatation  of  the  chest  more  apt  to  be  one-sided. 


326  MEDICAL    DIAGNOSIS. 

Yet  too  much  stress  has  been  laid  on  the  latter  point  as  a  means 
of  distinction  ;  for  emphysema  may  be  one-sided,  and,  on  the 
other  hand,  pneumothorax,  as  the  cases  of  Stokes  and  of  Reynaud* 
prove,  and  as  I  know  from  meeting  with  several  instances,  may 
occur  on  both  sides.  In  some  cases  we  are  aided  in  the  discrimi- 
nation by  noticing  that  bulging  is  perceptible  over  the  displaced 
heart,  and  that  a  metallic  echo  follows  the  cardiac  sounds. 

The  physical  signs  of  the  two  diseases  are  thus  very  different ; 
so,  too,  are  many  of  the  symptoms.  Difficulty  of  breathing  exists 
in  both.  But  in  emphysema  it  takes  more  the  form  of  attacks 
of  asthma ;  besides,  whether  spasmodic  or  not,  it  does  not  set  in 
suddenly  and  with  intensity,  and  remain  intense.  In  pneumo- 
thorax the  patient  remembers  to  have  been  seized  with  a  pain  in 
his  chest,  since  which  period  he  has  been  continuously  very  short 
of  breath. 

Yet  there  are  exceptions  to  this:  there  are  cases  in  which  the 
symptoms  occasioned  by  perforation  of  the  pleura  are  from  the 
onset  so  slight  as  not  to  attract  the  least  attention.  Such  cases 
cannot  be  recognized,  save  by  their  physical  signs.  Among  these, 
dilatation  of  the  chest,  with  the  widened  intercostal  spaces,  the 
displacement  of  the  liver  or  heart,  and  the  exaggerated  and  altered 
resonance  on  percussion  are  most  valuable  in  preventing  the  dis- 
ease from  being  confounded  with  some  affections  which  otherwise 
give  rise  to  many  of  the  same  phenomena.  In  large  cavities,  for 
instance,  the  respiration  and  voice  may  be  metallic;  metallic  tink- 
ling, nay,  even  a  succussion  sound,  may  occur.f  But  the  prominent 
chest,  the  extremely  clear,  tympanitic,  or  metallic  sound  on  percus- 
sion, bordered  by  the  line  of  absolute  dulness  due  to  the  effusion, 
are  not  met  with.  The  history  also  is  different,  and  the  dyspncea 
is  not  so  great.  The  same  dissimilarities  will  prevent  us  from 
mistaking  for  pneumothorax  a  pneumonia  in  which,  by  way  of 
exception,  the  percussion  sound  over  the  consolidated  lung  is  tym- 
panitic or  amphoric.  And  a  study  of  the  physical  signs,  too,  will 
at  once  enable  us  to  discern  whether  the  difficulty  in  breathing, 
though  it  be  suddenly  developed,  and  apparently  under  circum- 


*  Journ.  Hebdomad.,  tome  vii.,  1830. 

j  Cases  cited  by  Gendrin,  Gaz.  des  Hopit.,  No.  113,  1847;  and  Wintrich, 
Krankbeiten  der  Respirations-Organe,  page  367. 


DISEASES    OF    THE    LUNGS.  327 

stances  which  make  the  swallowing  of  a  foreign  body  seem  likely, 
be  due  to  this  cause,  or  to  perforation  of  the  pleura  and  pneumo- 
thorax.* 

There  is,  however,  a  morbid  condition  which  exhibits  nearly 
all  the  signs  and  many  of  the  symptoms  of  pneumothorax,  and 
which,  were  it  more  frequent,  would  be  the  source  of  constant 
errors  of  diagnosis, — diaphragmatic  hernia. 

Of  this  rare  affection  we  know  but  little.  Yet,  thanks  to  Bow- 
ditch,  f  what  we  do  know  of  it  teaches  us  that  a  protrusion  of  the 
abdominal  organs  through  the  diaphragm  will  generally  dilate  one 
side  of  the  chest,  compress  the  lung,  and  displace  the  heart.  It 
will  do  more :  it  results  in  dyspnoea ;  and,  as  the  stomach  or  in- 
testines are,  for  the  most  part,  the  viscera  which  find  their  way 
into  the  chest,  metallic  tinkling  and  a  tympanitic  sound  on  per- 
cussion are  detected.  These  are  also  signs  of  pneumothorax. 
There  is,  indeed,  no  mode  of  separating  the  two  diseases,  except  by 
attention  to  the  history  of  the  case,  by  noting  that  the  dyspnoea 
of  the  former  suddenly  appears  and  as  suddenly  disappears,  that 
it  has  often  existed  from  birth,  and  that  the  metallic  tinkling 
happens  when  the  patient  is  not  breathing,  and  is  mixed  up  with 
the  rumbling  sound  arising  in  the  stomach  or  intestine. 

It  has  been  made  a  question  whether  we  can  distinguish  ordinary 
cases  of  pneumothorax  from  these  very  rare  ones  which  are  sup- 
posed to  occur  without  perforation.  Now,  even  admitting  that 
such  really  happen  as  a  sequence,  for  instance,  of  decomposition 
in  pleuritic  effusions,  there  are  no  signs  by  which  we  can  recognize 
them  with  certainty.  It  has  been  claimed  for  them  that  there  is 
no  antecedent  history  of  a  chronic  pulmonary  affection,  particu- 
larly of  phthisis,  that  there  is  not  that  suddenly  occurring  severe 
pain  and  extreme  dyspnoea,  that  the  sputum  and  breath  are 
never  offensive,  that  metallic  tinkling  is  absent,  or  rare  and 
inconstant,  and  that  the  amphoric  breathing  is  not  so  well  de- 
veloped or  so  clearly  defined.  If  in  a  case  of  perforation,  how- 
ever, the  opening  have  closed,  the  physical  signs,  it  is  granted, 
are  the  same.J 


*  As  in  a  case  of  the  disease  communicated  to  me  by  Dr.  Walter  F.  Atlee. 
f  Buffalo  Med.  Journ.,  June  and  July,  18-53. 
%  Boisseau,  Arch.  Gen.  de  Med.,  vol.  ii.,  1867. 


328  MEDICAL    DIAGNOSIS. 

Chronic  Pleurisy. — Chronic  pleurisy  is  the  third  of  the 
group  of  more  usual  affections  which  are  characterized  by  dilata- 
tion of  the  chest,  by  displacement  of  the  intra-thoracic  viscera, 
and  by  shortness  of  breath.  It  is  true  that  acute  pleurisy  in  the 
stage  of  effusion  would,  strictly  speaking,  find  here  a  place;  but 
the  acute  symptoms  bring  it  into  another  class  with  which  it  lias 
been  more  conveniently  described. 

Chronic  pleurisy  is  established  if  the  fluid,  after  an  acute  attack, 
be  not  absorbed,  or  if  an  accumulation  of  liquid  take  place  grad- 
ually, in  consequence  of  subacute  inflammation  of  the  pleura. 
The  disease  has  no  constant  symptoms,  and  is  often  remarkably 
latent :  the  patient  frequently  does  not  remember  to  have  had 
acute  pleurisy.  He  is  not  commonly  troubled  with  much  cough, 
nor  is  the  want  of  breath  so  great  as  might  be  expected ;  he  is  not 
capable  of  talking  for  any  length  of  time,  or  in  a  loud  voice,  but 
he  does  not  really  suffer  from  dyspnoea.  His  general  health  may 
remain  good,  and  no  emaciation  occur.  In  some  persons,  on  the 
other  hand,  the  loss  of  flesh,  the  quickened  pulse,  the  sweats,  the 
paroxysms  of  hectic  fever,  are  so  marked  as  to  produce  a  close 
resemblance  to  the  last  stages  of  tubercular  consumption. 

While  the  differing  symptoms  rather  hide  the  pleurisy  from 
detection,  the  physical  signs  render  it  easy  of  recognition.  What 
these  signs  are,  need  not  be  repeated ;  they  have  been  fully  studied 
in  describing  the  effusion  in  acute  pleurisy.  It  is  only  necessary 
to  recall  that  the  most  significant  are  absent  respiration  and  voice, 
a  flat  sound  on  percussion,  with  a  vesiculobronchial  or  a  bronchial 
respiration  above  the  seat  of  the  liquid.  The  intercostal  spaces 
are  obviously  widened ;  their  depressions  are  effaced.  They  are, 
indeed,  sometimes  convex,  and  the  finger  pressed  on  them  detects 
a  distinct  fluctuation.  During  the  act  of  breathing,  the  diseased 
side  is  almost  motionless,  presenting  a  strong  contrast  to  the  obvious 
play  of  the  healthy  side.  The  lung  which  is  not  disturbed  in- 
creases in  size.  Its  murmur  is  more  intense,  sometimes  harsher ; 
and  the  percussion  sound  over  it  is  exceedingly  clear.  In  some 
cases  it  becomes  emphysematous.  The  heart  or  liver  is  displaced. 
A  lateral  curvature  of  the  spinal  column  is  apt  to  take  place,  and 
the  shoulder,  as  Corson  points  out,  remains  fixed  and  stiff  during 
the  respiratory  acts.  To  distinguish  whether  the  fluid  is  collected 
in  one  cavity  or  in  several,  in  other  words,  whether  unilocular 


DISEASES    OF    THE    LUXGS.  329 

or  multilocular,  is  generally  impossible.  Jaccoud*  has,  however, 
forcibly  called  attention  to  some  points  which  aid  in  arriving  at  a 
conclusion.  If  we  have  a  zone  in  the  dulness  where  vocal  vibra- 
tions are  preserved,  as  at  the  posterior  part  of  the  chest  from  along 
the  vertebral  column  toward  the  sternum,  and  beyond  this  zone 
no  vibrations  are  perceived,  we  may  infer  that  the  effusion  is 
divided  by  a  band  of  pleural  adhesion ;  if  the  voice  and  fremitus 
be  preserved,  although  weakened,  over  the  whole  extent  of  the 
dulness,  except  in  a  zone  of  a  few  finger-breadths  at  the  lower 
part  of  the  chest  behind,  while  no  tympanitic  sound  is  elicited 
under  the  clavicle,  we  are  to  conclude  that  the  pleurisy  is  multi- 
locular. When  adhesions  to  the  diaphragm  exist,  the  normal 
movements  during  respiration  at  the  epigastrium  and  hypochon- 
driuni  are  reversed,  and  at  each  inspiration  a  marked  depression 
of  the  inferior  intercostal  spaces  is  perceptible. 

Effusions  into  the  pleural  sac  may  last  for  a  long  time,  and 
lead  to  death  by  progressive  exhaustion;  or  the  patient  may  re- 
cover by  the  fluid  being  absorbed,  or  by  its  finding  a  vent  through 
the  bronchial  tubes  or  the  thoracic  walls.  But  the  chest  is  rarely 
restored  to  its  former  state.  The  lung  was  too  much  compressed, 
or  is  still  bound  down  by  too  firm  adhesions,  to  resume  its  full 
share  in  the  function  of  respiration.  The  walls  of  the  chest  sink 
in  around  it,  and  the  side  is  flattened,  sounds  duller  on  percussion, 
and  presents  a  feebler  breathing  than  the  other  lung,  which  re- 
mains somewhat  enlarged.  The  heart  generally  returns  to  its 
normal  position,  but  the  shoulder  on  the  affected  side  is  apt  to 
show  a  permanent  depression. 

Notwithstanding  the  decided  character  of  the  physical  signs, 
it  is  astonishing  how  frequently  chronic  pleurisy  is  overlooked. 
The  only  explanation  of  this  is,  that  so  little  attention  is  paid 
to  the  signs.  Were  the  chest  more  often  carefully  explored,  we 
should  cease  to  hear  of  patients  whose  pleural  cavity  is  filled  with 
pus  being  pronounced  incurable  consumptives,  because  they  are 
emaciating  and  have  hectic  fever  and  clubbed  nails;  or  being 
treated  for  disease  of  the  heart,  on  account  of  the  displacement 
of  that  organ,  and  of  dyspnoea  and  cedema ;  or  being  dosed  with 
mercury,  for  an  imaginary  disorder  of  the  liver ;  or  being  subjected 

*  Bulletin  de  l'Academie  de  Medecine,  1879. 


330  MEDICAL    DIAGNOSIS. 

to  long  courses  of  quinia  and  arsenic,  to  check  a  rebellious  ague 
which  the  chilly  sensations  and  paroxysms  of  fever  at  times 
simulate. 

These  physical  signs  are  the  same  whether  the  fluid  be  serum 
or  pus.  The  character  of  the  fluid  produces,  indeed,  no  distinct- 
ive changes,  either  in  the  signs  or  in  the  symptoms.  We  suspect 
empyema  if  the  emaciation  be  great  and  accompanied  by  a  quick 
pulse,  high  temperature,  and  hectic  fever.  Quite  recently  Baccelli 
has  proposed  a  new  and  simple  test  to  determine  the  character  of 
the  fluid,  which  has  not  as  yet,  however,  been  definitely  proved. 
It  consists  in  ascertaining  accurately  how  the  voice  penetrates, 
especially  the  whispered  voice.  If  easily  and  thoroughly  trans- 
mitted, the  liquid  is  serous  and  homogeneous;  if  with  difficulty, 
it  is  fibrinous  or  purulent;  if  not  at  all,  it  is  most  apt  to  be  the 
latter.  In  cases  of  much  doubt,  I  am  in  the  habit  of  using  a 
hypodermic  syringe,  and  removing  with  it  enough  of  the  fluid 
for  microscopical  examination. 

"When  we  come  to  inquire  into  the  thoracic  diseases  with  which 
chronic  pleurisy  is  likely  to  be  confounded,  we  shall  find  that, 
although  many  have  some  signs  in  common,  few,  if  any,  present 
the  same  association  of  signs.  Leaving  out  the  malady  which  is 
most  commonly  mistaken  for  it, — pulmonary  consumption, — since 
the  points  of  difference  have  already  been  fully  discussed,  the 
affections  with  which  chronic  pleurisy,  while  the  pleura  is  full  of 
liquid,  and  the  chest  consequently  enlarged,  is  liable  to  be  con- 
founded, are : 

Emphysema  and  Pneumothorax  ; 

Intra-thoracic  Tumor; 

Enlargement  of  the  Liver; 

Enlargement  op  the  Spleen; 

Abscess  in  the  Thoracic  "Walls  ; 

Pericardial  Effusion  ; 

Hydrothorax. 

Emphysema  and  Pneumothorax. — These,  although  distinct  dis- 
eases, are  grouped  together  because  they  agree  in  possessing  phys- 
ical signs  indicative  of  an  increased  quantity  of  air  within  the 
chest;  and  they  give  rise,  like  chronic  pleurisy,  to  a  dilated  chest, 
and  to  displacement  of  the  liver  or  heart.  But  the  other  signs 
above   pointed    out,  which  are  due  to  the  presence  of  air,  are 


DISEASES    OF    THE    LUNGS.  331 

so  striking,  that  an  error  in  diagnosis  can  only  be  the  result  of 
carelessness. 

Intra-thoracic  Tumor. — A  tumor  within  the  chest  may  occasion 
the  same  distention  of  its  walls,  the  same  displacement  of  organs, 
the  same  dulness  on  percussion,  and  the  same  absent  respiration,  as 
an  effusion  of  liquid  into  the  pleura;  yet  the  signs  are  not  exactly 
alike.  There  is  no  fluctuation  in  the  bulging  intercostal  spaces ; 
the  vocal  fremitus  is  not  so  constantly  abolished ;  and  the  level  of 
the  dulness  is  not  changed  by  altering  the  patient's  position.  JSTor 
is  the  flat  sound  so  uniform  or  so  strictly  limited  as  that  produced 
by  fluid :  amid  the  dulness  may  be  detected  here  and  there  a  spot 
yielding  on  percussion  a  clear  sound.  A  tumor  in  the  chest,  more- 
over, presses  on  the  nerves,  or  bronchial  tubes,  or  great  vessels, 
and  thus  gives  rise  to  severe  pain,  and  to  dyspnoea  and  signs  of  in- 
terrupted circulation  far  more  evident  than  are  caused  by  a  pleu- 
ritic effusion.  It  not  infrequently  grows  into  the  mediastinum,  and 
then  leads  to  prominence  of  the  sternum,  and  to  dilatation  of  both 
sides  of  the  chest.  These  phenomena  are  found,  whatever  be  the 
nature  of  the  morbid  growth.  As  most  of  the  thoracic  tumors 
are  cancerous,  we  are  often  assisted  in  our  diagnosis  by  discover- 
ing a  cancer  in  other  parts  of  the  body,  and  by  noting  the  severe 
pain  in  the  chest,  the  harassing  cough,  and  the  expectoration  of 
blood,  or  of  a  peculiar  jelly-like  substance.  Yet  these  evidences, 
while  they  aid  us  in  establishing  the  fact  of  a  morbid  growth  in 
the  thoracic  cavity,  do  not  by  any  means  determine  its  situation. 
We  cannot  go  a  step  further,  and  say,  with  certainty,  whether  the 
abnormal  formation  be  situated  exclusively  in  the  lung,  or  in  the 
pleura,  or  w7hether  it  affect  both. 

In  those  cases  in  which  an  effusion  into  the  pleura  complicates 
an  intra-thoracic  tumor,  attention  to  the  history  and  to  the  signs 
of  pressure  alone  apprises  us  of  its  presence.  Yet  both  signs  and 
symptoms  may  be  so  closely  like  those  of  chronic  pleurisy  as  to 
render  a  differential  diagnosis  impossible.  Nay,  friction  sounds, 
a  stitch  in  the  side,  and  fever  may  be  produced  by  a  cancer  of  the 
pleura,  and  be  apparently  so  rapidly  developed  as  to  cause  the 
disease  to  be  regarded  as  an  acute  or  subacute  inflammation  of 
that  membrane.  Cancer  of  the  pleura,  like  tubercle  of  this  struc- 
ture, has,  therefore,  no  pathognomonic  signs.  The  most  certain 
sign  of  cancer  of  the  pleura  is  probably  the  one  mentioned  by 


332  MEDICAL    DIAGNOSIS. 

Trousseau,  namely,  that  the  fluid  which  is  evacuated  by  paracen- 
tesis consists  of  a  bloody  serum. 

It  is  at  times  equally  impossible  to  distinguish  a  circumscribed 
pleurisy  from  a  tumor  in  the  chest.  In  those  rare  cases  in  which 
adhesions  bound  the  liquid  effusion  and  encyst  it,  we  observe  all 
the  marks  of  a  tumor, — a  restricted  bulging  and  percussion  dul- 
ness,  and  an  absent  respiration.  Several  cysts  may  form  as  the 
result  of  successive  attacks  of  pleurisy,  and  may  exist  at  any  por- 
tion of  the  chest.  The  fluid  may  be  collected  in  the  mediastinum, 
or  between  the  lobes  of  the  lung,  or  anywhere  between  the  surfaces 
of  the  pleural  membrane.  The  purulent  contents  of  the  sac  some- 
times find  their  way  into  the  bronchial  tubes,  and  are  expectorated, 
or  give  rise  to  a  distinct  fluctuation  in  the  intercostal  spaces,  and 
then  discharge  through  the  thoracic  parietes.  In  such  cases  the 
diagnosis  is  not  difficult.  But  where  these  phenomena  are  not 
present,  the  dissimilar  history  of  the  case  and  the  absence  of 
symptoms  of  pressure  are  the  only  means  of  distinction  from  a 
tumor  in  the  chest.  Fortunately  for  the  diagnostician,  encysted 
pleurisy  is  a  rare  disease;  were  it  frequent,  it  would  be  a  fruitful 
source  of  error.  The  same  remark  applies  to  those  cysts  known 
as  hydatid,  and  which  may  occasion  all  the  signs  of  a  circum- 
scribed pleurisy.*  An  examination  of  the  fluid  obtained  by  an 
exploratory  puncture,  in  which  echinococci  are  found,  is  the  only 
positive  test. 

Enlargement  of  the  Liver. — An  enlarged  liver  usually  descends 
into  the  abdominal  cavity ;  yet  it  may  be  forced  upward  as  far  as 
the  fourth  rib,  and,  by  encroaching  upon  the  lung,  may  give  rise 
to  many  of  the  physical  signs  of  a  pleuritic  effusion.  The  surest 
diagnostic  test  is,  that  during  full  inspiration  and  expiration  the 
line  of  dulness  descends  and  ascends;  while  the  flat  sound  of  a 
pleuritic  effusion  is  not  affected  by  the  play  of  the  lungs.  This 
test  will  be  applicable,  except  where  the  liver  is  firmly  adherent 


*  See  the  observations  of  Vigla,  Arch.  Gen.  de  Med.,  Sept.  and  Nov.  1855, 
and  of  Koger,  ibid.,  Nov.  18G1 ;  also  cases  quoted  in  Schmidt's  Jahrb.,  No. 
10,  1809,  and  in  London  Lancet,  July,  1871,  where  they  are  stated  to  be 
frequent  in  Australia;  also  experiences  of  Bird,  ibid.,  March,  1877  ;  Lebert's 
Klinik  der  Brustkrankheiten,  Bd.  ii. ;  and  compare  the  cases  of  circum- 
scribed pleurisy  in  Blakiston's  Practical  Observations  on  Diseases  of  the  Chest, 
and  in  Durrani's  paper,  Prov.  Med.  and  Surg.  Journ.,  1849. 


DISEASES    OF    THE    LUNGS.  333 

to  the  walls  of  the  abdomen.  As  circumstances  to  assist  in  dis- 
criminating between  the  enlargement  of  the  abdominal  organ 
and  the  presence  of  liquid  in  the  chest,  may  be  mentioned  that 
the  heart,  if  at  all  displaced,  is  pushed  upward,  and  not  toward 
the  side;  that  the  dulness  of  an  enlarged  liver  extends  higher 
up  anteriorly  than  posteriorly,  which  is  the  reverse  of  what 
takes  place  in  a  pleuritic  effusion .  Moreover,  the  respiration 
at  the  lower  portion  of  the  lung  posteriorly,  although  enfeebled, 
is  still  audible.  But  there  may  be  very  considerable  difficulties 
in  diagnosis,  as  we  may  learn  from  some  of  the  cases  recorded  by 
Toulmouche.* 

Enlargement  of  the  Spleen. — An  enlarged  spleen  is  attended 
with  prominence  and  with  dulness  on  percussion  at  the  lower 
part  of  the  chest  on  the  left  side,  and  might,  therefore,  mislead 
into  the  idea  of  a  pleuritic  effusion.  Error  in  diagnosis  is  pre- 
vented by  attention  to  the  fact  that  the  dulness  extends  also 
downward  and  toward  the  median  line.  Again,  the  heart  is  not 
laterally  displaced,  but  tilted  upward ;  the  respiration  is  feeble, 
but  not  absent;  and  the  vocal  vibrations  are  mostly  unimpaired. 

Abscess  in  the  Thoracic  Walls. — This,  too,  leads  to  local  tume- 
faction and  fluctuation ;  but  we  can  always  ascertain  whether  a 
fluctuating  tumor  in  the  intercostal  spaces  communicates  with  the 
pleural  cavity  or  not — whether,  in  other  words,  it  is  or  is  not  the 
result  of  an  effusion  which  is  pointing  externally — by  watching 
how  pressure  and  the  acts  of  respiration  affect  it.  For,  unless  the 
diaphragm  have  become  immovable  from  the  extent  of  the  effu- 
sion, a  bulging  which  is  in  connection  with  the  pleura  is  dimin- 
ished' during  a  full  inspiration,  and  becomes  more  prominent 
when  the  diaphragm  ascends  in  expiration.  The  swelling,  more- 
over, can  be  made  to  disappear  to  some  extent  by  pressure.  It  is 
not  so  with  an  abscess  seated  in  the  walls  of  the  chest.  It  is 
not  reducible,  and  does  not  recede  during  inspiration. 

Pericardial  Effusion. — An  effusion  into  the  pericardium  cannot 
be,  certainly  ought  not  to  be,  mistaken  for  an  effusion  into  the 
pleura.  The  first  induces  prominence  and  increased  dulness  on 
percussion  over  the  region  of  the  heart;  the  second,  dulness  and 
prominence  over  the  back  part  as  well  as  over  the  front  of  the 

*  Arch.  Gen.  de  Med.,  Sept.  1873. 


334  MEDICAL   DIAGNOSIS. 

lung.  A  few  cases  are,  however,  recorded  in  which  an  enormously 
distended  pericardial  sac  produced  a  flat  sound  posteriorly,  and 
gave  rise  to  signs  of  compression  of  the  lung.  But  in  these  at- 
tention to  the  feeble  impulse  of  the  heart  and  its  muffled  sounds 
permitted  it  to  be  foretold  that  fluid  had  accumulated  in  the  peri- 
cardium, and  not  in  the  pleura. 

Hydrothorax. — A  dropsy  having  its  seat  in  the  pleural  cavity  is 
called  hydrothorax,  or  water  on  the  chest.  The  term  is,  in  truth, 
sufficiently  significant,  the  fluid  which  is  poured  out  being  very 
thin  and  watery.  The  physical  signs  of  hydrothorax  are  the 
same  as  those  of  an  effusion  due  to  inflammation ;  but,  as  the 
dropsy  results  from  an  organic  disease  of  the  liver,  heart,  or  kid- 
neys, the  serum  collects  in  both  pleural  sacs.  Now,  an  effusion 
caused  by  an  inflammation  of  the  pleura  is  nearly  always  one- 
sided. Even  where  both  pleurae  are  filled  with  fluid, — a  rare 
condition,  except  in  tubercular  pleurisy, — one  is  affected  before 
the  other.  This  does  not  happen  in  hydrothorax.  Thus  the 
double-sided  effusion,  and  its  usual  association  with  dropsies  in 
other  parts  of  the  body,  are  matters  of  much  significance.  Be- 
sides, in  forming  a  diagnosis  of  hydrothorax  we  may  lay  some 
stress  on  the  absence  of  friction  sounds ;  on  the  smaller  quantity 
of  fluid ;  on  the  history  of  the  malady ;  and  on  the  presence  of  a 
structural  lesion  of  the  liver,  kidneys,  or  heart. 

These,  then,  are  the  diseases  with  which  chronic  pleurisy,  when 
it  produces  dilatation  of  the  chest,  may  be  confounded.  I  have 
entered  into  the  subject  somewhat  at  length,  because,  in  view  of 
the  frequency  of  the  operation  of  paracentesis,  it  is  important  to 
know  what  affections  besides  chronic  pleurisy  may  lead  to  promi- 
nence of  the  chest  and  to  compression  of  the  lung.  It  is  well  to 
be  able  to  prove  that  none  of  them  is  present  before  a  trocar  is 
plunged  through  the  intercostal  spaces. 

The  operation  of  tapping  the  chest  has  certain  diagnostic  bear- 
ings which  may  be  here  alluded  to.  One  of  these  is  an  albumi- 
nous expectoration  that  follows,  which  may  be  looked  upon  as  a 
passing  albuminuria  due  to  circulatory  disturbances.  It  is  not  an 
unfavorable  event ;  on  the  contrary,  in  cases  in  which  it  happens 
retraction  of  the  thoracic  parietes  is  less  likely  to  occur.* 

*  Legroux,  Arch.  Gen.  de  Med.,  Aug.  1873. 


DISEASES    OF    THE    LUNGS.  335 


Diseases  in  which  Eetraction  of  the  Chest  occurs. 

Chronic  Pleurisy. — We  may  here  continue  the  description 
of  chronic  pleurisy  in  the  stage  of  absorption,  since  it  is  under 
these  circumstances  that  the  most  marked  retraction  of  the  walls 
of  the  chest  takes  place.  This  shrinking  of  the  thoracic  parietes 
is  not  a  sudden,  but  a  gradual  act,  and  instances  are  therefore  con- 
stantly met  with  in  which  the  upper  part  of  the  chest  is  flattened 
and  the  lower,  owing  to  its  still  containing  fluid,  bulges.  The 
contraction  of  one  side  of  the  thorax  attains  its  highest  degree 
when  the  effusion  in  the  pleura  is  discharged  through  the  chest- 
walls  and  external  fistulous  openings  are  established. 

The  symptoms  in  the  stage  of  retraction  are  those  of  chronic 
pleurisy  with  dilatation  of  the  chest,  and  present,  therefore,  the 
same  variableness.  But  oedema  of  the  affected  side,  which  is  some- 
times so  striking  a  symptom  of  chronic  pleurisy  when  the  effusion 
is  considerable,  is  here  not  noticed.  The  physical  signs  alter 
somewhat,  according  to  the  presence  or  absence  of  fluid  in  the 
pleural  sac.  When  none  exists,  respiration  is  heard  all  over  the 
lung  as  a  feeble  inspiration  with  prolonged  expiration,  or  as  an 
indistinct  blowing ;  and  now  and  then  a  friction  sound  may  be 
caught.  When  the  pleura  still  contains  liquid,  these  signs  occur 
at  the  upper  portion  of  the  chest,  and  a  much  more  absolute  d ill- 
ness on  percussion,  an  absent  voice  and  vocal  fremitus  at  the  lower 
part  denote  that  fluid  has  there  accumulated.  The  heart  is  found 
either  in  its  normal  position  or  still  displaced.  The  force  with 
which  contraction  takes  place  may  pull  it  over  to  the  side  on 
which  the  shrinking  is  going  on. 

Now,  it  is  evident  that  chronic  pleurisy,  when  leading  to  re- 
traction of  one  side  of  the  chest,  cannot  be  mistaken  for  diseases 
attended  with  thoracic  distention;  but  it  may  be  mistaken  for 
affections  like  pulmonary  cancer,  tubercle,  and  chronic  consolida- 
tion, which  also  occasion  a  flattening  of  the  chest-walls. 

From  cancer  we  distinguish  it  by  the  absence  of  the  peculiar 
expectoration,  and  of  hemorrhage ;  by  the  want  of  signs  of  per- 
fect consolidation ;  and  by  the  dissimilar  history.  We  distinguish 
it  from  tubercle  by  the  diminution  of  the  chest  in  the  latter  not 
being  confined  to  one  side;  by  the  physical  signs  indicative  of 
deposit  and  softening  at  the  upper  portions  of  the  lungs;  by  the 


336  MEDICAL    DIAGNOSIS. 

presence  of  rales ;  by  the  occurrence  of  hemorrhage ;  and  by  the 
greater  emaciation. 

Chronic  pneumonic  consolidation  presents,  on  the  whole,  most 
points  of  resemblance.  But  there  is  this  difference  :  the  shrinking 
of  the  side  in  chronic  pneumonia  is  less  marked,  and  is  confined 
to  the  part  involved, — usually  the  lower  lobe  of  the  lung.  The 
retraction  is  much  more  general  in  chronic  pleurisy;  or  where  it 
is  partial,  it  is  the  upper  segment  of  one  side  of  the  chest  which  is 
flattened, — the  lower  is  prominent,  and  sounds  very  dull  on  per- 
cussion, shows  no  change  on  respiratory  percussion,  and  yields  the 
ordinary  physical  evidences  of  fluid.  In  the  former  malady  the 
blowing  respiration,  or  the  enfeebled  inspiration  and  prolonged 
expiration,  and  the  distinct  voice  are  heard  only  over  the  consol- 
idated lobe;  in  the  other  lobes  the  breathing  is  plainly  vesicular. 
In  chronic  pleurisy  the  same  abnormal  signs,  except  perhaps  the 
increased  voice,  are  either  manifest  over  an  entire  side,  or  they  are 
perceived  over  the  narrowed  portion  of  the  chest,  and  at  the  lower 
part  the  respiration,  voice,  and  fremitus  are  abolished. 

In  that  form  of  chronic  pulmonary  induration  attended  com- 
monly with  dilatation  of  the  bronchial  tubes,  to  which  the  name 
of  cirrhosis  of  the  lung,*  or  fibroid  j^hthisis,  has  been  given,  the 
flattening  of  the  affected  side  is  as  obvious  as  it  is  in  pleurisy. 
In  truth,  the  two  disorders  bear  a  strong  relation  to  each  other. 
The  increased  formation  of  connective  tissue  in  the  pleuritic  ad- 
hesions passes  on  into  the  lung,  occasioning  an  interstitial  pneu- 
monia,— though  the  fibroid  change  may  begin  in  the  lung, — and, 
as  this  progresses  and  the  lung  shrinks,  bronchial  dilatations  usu- 
ally follow.  We  distinguish  cirrhosis  of  the  lung  by  the  copious 
and  peculiar  sputum  which  attends  the  bronchial  affection  ;  by  the 
rales;  by  the  harsh  or  bronchial  or  tubular  or  feeble  respiration; 
by  the  dulness  on  percussion  with  an  occasional  tympanitic  note ; 
by  the  marked  resistance  of  the  chest- walls;  by  the  increased  vocal 
resonance;  by  the  narrowing  of  the  intercostal  spaces;  and  by  the 
displaced  apex  beat, — drawn  up,  if  the  disorder  be  on  the  left  side, 
one  or  several  intercostal  spaces,  or  so  covered  by  the  expanded 
left  lung,  if  the  disorder  be  on  the  right,  as  to  be  imperceptible, 
unless  the  shrinking  of  the  affected  lung  be  considerable,  when 

*  Corrigan,  Dublin  Quart.  Journ.,  vol.  xiii. 


DISEASES    OF    THE    LUNGS.  337 

the  heart  may  be  found  drawn  over  on  the  diseased  side.  Fur- 
ther signs  of  the  complaint,  when  the  malady  is  left-sided,  are 
that  in  the  second  intercostal  space  to  the  left  of  the  sternum  a 
double  beat  of  the  pulmonary  artery  is  perceptible,  and  that 
whichever  side  is  diseased  shows  the  diaphragm  greatly  displaced 
upward,  and  a  marked  vesicular  resonance  in  a  line  along  the 
edge  of  the  sternum  caused  by  the  overlapping  of  the  healthy 
lung,  and  in  strong  contrast  with  the  line  of  dulness  of  the  cir- 
rhosed  organ.*  The  affection  is  a  very  chronic  one,  and  unat- 
tended with  fever  or  laryngeal  symptoms.  Loss  of  flesh  and  of 
strength  are  very  gradual,  and  night-sweats  are  slight  or  incon- 
stant. Dilatation,  or  hypertrophy  with  dilatation,  of  the  right  side 
of  the  heart  and  dropsy  are  not  infrequent,  and  haemoptysis  is  still 
oftener  met  with.  The  disease  has  among  its  causes  the  inhalation 
of  fine  particles,  such  as  of  steel,  of  coal-dust,  of  cotton.  It  may 
have  an  obscure  beginning,  or  it  may  clearly  date  from  an  acute 
catarrhal  pneumonia  or  plastic  pleurisy.  It  very  rarely  becomes 
complicated  with  tubercle.  The  fibroid  condition  of  the  lungs — 
also  called  by  some  fibroid  phthisis — in  old  tubercular  lungs  or 
around  cavities  is  an  evidence  rather  of  a  disposition  toward 
healing,  and  is  not  the  disease  under  consideration.  Pulmonary 
cirrhosis  not  unfrequently  proves  fatal  from  an  acute  affection,  a 
broncho-pneumonia  or  pneumonia,  of  the  previously  healthy  lung. 

A  collapsed  state  of  the  lung,  resulting  from  a  plug  of  mucus 
in  the  bronchial  tubes,  may,  in  rare  instances,  yield  the  mani- 
festations of  chronic  pleurisy  with  partial  retraction.  No  signs 
distinguish  such  cases,  except  the  more  limited  depression ;  the 
absence  of  any  disease  above  the  flattened  spot;  the  want  of 
friction  sound,  and  of  tenderness  on  pressure;  and  the  rapid  dis- 
appearance of  the  physical  phenomena  after  an  effort  of  coughing 
has  removed  the  obstruction. f 

Where  external  fistulous  openings  exist,  the  shrinking  of  the 
side,  as  already  stated,  is  carried  to  the  highest  degree.  These 
fistula?,  whether  produced  artificially  or  by  nature,  may  close  after 
they  have  served  the  purpose  of  evacuating  the  fluid  in  the  pleural 


*  Nothnagel,  Sammlung  Klinischer  Yortrage,  1874. 

f  An  interesting  instance  of  this  kind  is  related  by  the  late  Prof.  Pepper  in 
the  American  Journal  of  the  Medical  Sciences  for  April,  1852. 

22 


338  MEDICAL    DIAGNOSIS. 

cavity.  But  they  often  persist  for  months  or  years,  and  keep  on 
discharging  offensive,  purulent  matter.  The  patient  emaciates 
under  this  continued  drain,  yet  not  so  quickly  as  might  be  imagined. 
More  or  less  troublesome  cough  annoys  him,  but  it  is  not  ordi- 
narily accompanied  by  much  expectoration.  Every  now  and 
then,  however,  he  discharges  for  days  a  quantity  of  fetid,  purulent 
sputum.  It  is  difficult  to  understand  why  this  happens.  It 
seems  certainly,  as  far  as  physical  signs  can  prove,  not  the  liquid 
in  the  pleura  which  is  being  voided  through  a  perforation  of  the 
pulmonary  tissue,  for  the  physical  signs  of  pneumothorax  are 
absent. 

The  clubbing  of  the  nails  is  often  extremely  marked,  and 
may  exist  to  an  extent  far  greater  than  in  phthisis.  The  nail  is 
rounded  and  bluish,  and  the  whole  end  of  the  finger  looks  en- 
larged. This  appearance  is  even  more  striking  than  the  curve 
of  the  nail.  The  nails  and  last  joints  of  the  toes  show  the  same 
alteration. 

The  fistulous  opening  is  situated  ordinarily  in  the  intercostal 
space  below  the  nipple.  It  may,  however,  be  seated  at  the  back 
of  the  chest,  and  communicate  by  a  tortuous  sinus  with  the  intes- 
tine and  other  abdominal  viscera.  If  it  pass  into  the  lung,  the 
physical  evidences  of  pneumothorax  are  present,  but  the  side  is 
still  retracted,  and  striking  the  chest  elicits  a  mixture  of  a  dull 
and  a  tympanitic  sound.  Where  merely  an  external  opening 
exists,  no  signs  of  pneumothorax  occur,  because  no  air  finds  its 
way  into  the  pleural  cavity. 

A  fistulous  opening  into  the  pleura  is  not  difficult  of  diagnosis. 
It  is  easy  to  establish  the  fact  that  the  fistula  is  not  simply  pro- 
duced by  caries  of  the  rib ;  for  a  probe  may  be  run  into  the  chest 
for  two,  three,  or  four  inches. 

I  base  these  statements  on  a  number  of  instances  of  chronic 
pleurisy  attended  with  external  fistula  which  have  come  under 
my  notice.  The  seat  of  the  opening  near  the  nipple ;  the  peculiar 
nail;  the  occasional  flow  for  days  of  a  most  offensive  sputum 
from  the  bronchial  tubes,  without  any  traces  of  pneumothorax; 
the  ease  with  which  the  fistula  could  be  probed,  and  its  depth ; 
the  gradual  emaciation ;  and,  I  may  add,  the  decided  improve- 
ment under  the  persistent  use  of  cod-liver  oil  and  tonics, — be- 
longed to  them  all,  and  justify  the  description  given. 


DISEASES    OF    THE    HEART.  339 

SECTION    II. 
DISEASES   OF   THE   HEAET. 

The  diagnosis  of  affections  of  the  heart  turns  so  completely 
upon  a  knowledge  of  its  anatomy  and  physiology  that  it  will  be 
necessary  to  recall  some  of  the  more  important  anatomical  and 
physiological  facts  connected  with  the  organ. 

The  heart  is  a  hollow  muscle  employed  in  forcing  blood  into 
all  parts  of  the  body.  It  is  kept  from  rolling  about  in  the  chest 
by  the  great  vessels  which  spring  from  its  base,  and  by  the  attach- 
ment to  the  diaphragm  of  its  membranous  covering, — the  peri- 
cardium. It  lies  obliquely  in  this  membrane,  with  its  long  axis 
directed  downward  and  toward  the  left.  Its  broad  end,  or  base, 
points  backward  and  upward  toward  the  right  shoulder ;  its  under 
side  rests  upon  the  central  tendon  of  the  diaphragm.  The  interior 
of  the  heart  is  lined  by  a  serous  membrane, — the  endocardium, 
— which  is  reflected  over  the  valves.  These  valves  all  lie  in  close  / 
proximity  to  one  another,  and  within  a  space  of  less  than  an  inch  y. 
square. 

The  relations  the  different  parts  of  the  organ  bear  to  the  chest- 
walls  are  as  follows.  The  auricles  are  on  a  line  with  the  third 
costal  cartilages  •  the  right  auricle  extends  across  the  sternum  to 
the  right  side  of  the  chest.  The  right  ventricle  is  placed  partly 
under  the  sternum,  and  partly  to  the  left  of  it.  Its  inferior  bor- 
der is  on  a  level  with  the  sixth  cartilage.  The  left  ventricle  lies 
within  the  nipple,  between  the  third  and  fifth  intercostal  spaces. 
The  apex  is  seated  between  the  cartilages  of  the  fifth  and  sixth 
ribs,  to  the  inner  side  of,  and  from  an  inch  and  a  half  to  two 
inches  below,  the  left  nipple.  The  base  of  the  heart  corresponds 
posteriorly  to  the  sixth  and  seventh  dorsal  vertebra?,  from  which 
it  is  separated  by  the  aorta  and  cesophagus.  The  greater  portion 
of  the  anterior  surface  of  the  heart  is  removed  from  the  thoracic 
walls  by  the  lungs.  The  right  lung  extends  to  the  middle  of  the 
sternum.  The  left  lung  spreads  out  as  far  as  the  fourth  cartilage, 
and  covers  the  whole  of  the  left  ventricle,  except  the  apex.  The 
part  of  the  heart  which  remains  exposed  consists  thus  mainly  of 


340 


MEDICAL,    DIAGNOSIS. 


the  lower  portion  of  the  right  ventricle ;  it  presents  the  shape  of 
a  rude  triangle. 

The  position  of  the  valves  can  be  learned  by  running  needles 
into  the  chest  before  the  viscus  is  taken  out.  In  this  manner  it  is 
ascertained  that  at  the  left  border  of  the  sternum,  on  a  level  with 
the  third  intercostal  space,  lies  the  mitral  valve,  and  in  front  of 
this,  more  directly  under  the  sternum,  and  but  a  few  lines  lower, 

Fig.  30. 


Topography  of  the  heart.  The  relations  of  each  portion  of  the  heart  to  the 
walls  of  the  chest  are  shown.  The  dotted  lines  mark  the  lungs.  The  figure 
is  based  upon  several  careful  dissections. 


the  tricuspid  valve.  The  pulmonary  orifice  is  seated  opposite  the 
junction  of  the  cartilage  of  the  third  rib  with  the  left  edge  of  the 
sternum.  Near  it,  very  slightly  lower,  but  placed  more  obliquely, 
are  the  aortic  valves.  The  aorta  then  proceeds  from  left  to  right, 
and  ascends  to  the  upper  border  of  the  second  costal  cartilage  on 
the  right  side;  thence  it  crosses,  under  the  sternum  and  in  front 
of  the  trachea,  to  the  left  side.  The  pulmonary  artery  is  found 
in  the  second  intercostal  space  on  the  left  side,  enclosed  in  the 


DISEASES    OF    THE    HEART.  341 

pericardium,  and  passes  to  the  cartilage  of  the  second  rib,  where 
it  bifurcates. 

The  size  of  the  heart  is  about  that  of  the  closed  fist.  Its  mean 
weight  in  adults  is  estimated  by  Bouillaud  at  between  eight  and 
nine  ounces.     Only  in  very  large  persons  does  it  exceed  this. 

The  organ  exhibits,  when  in  action,  a  wonderfully  perfect 
mechanism  and  regularity  of  movement.  Its  cavities  contract  on 
both  sides  at  the  same  time,  and  distend  on  both  sides  at  the  same 
time.  It  then  rests  for  a  short  period.  The  contraction  of  the 
ventricles  occasions  the  impulse  which  is  seen  and  felt  in  the  fifth 
intercostal  space.  While  the  blood  is  flowing  in  and  out  of  the 
heart,  the  valves  are  kept  in  constant  motion.  Their  play  makes 
itself  known  by  two  distinct  sounds  of  unequal  length,  which  are 
produced  mainly  by  their  opening  and  closing. 

The  first  long  and  dull  sound  is  caused  by  the  forcible  closure 
of  the  valves  at  the  auriculo-ventricular  'openings.  Yet  it  is  not 
a  purely  valvular  sound.  The  stroke  of  the  heart  against  the 
walls  of  the  chest,  and  the  muscular  contraction  itself,  aid  in  its 
formation.  The  first  sound  corresponds,  therefore,  to  the  closure 
of  the  auriculo-ventricular  valves,  to  the  impulse  of  the  heart,  to 
the  opening  of  the  valves  at  the  orifice  of  the  aorta  and  of  the 
pulmonary  artery,  and  to  the  passage  of  blood  along  the  arteries. 
The  second  sound  is  short,  abrupt,  and  ringing.  It  results  from 
the  sudden  closure  of  the  semilunar  valves.  During  its  occurrence 
the  blood  rushes  through  the  opened  mitral  and  tricuspid  valves, 
and  dilates  the  ventricles. 

This  seems  to  be  the  simplest  explanation  of  the  sounds  of  the 
heart.  At  all  events,  it  is  the  one  best  supported  by  physiological 
proofs,  and  most  in  harmony  with  those  manifestations  of  disease 
by  which  nature  teaches  us,  more  certainly  even  than  vivisections 
do,  her  great  truths.  Yet  I  cannot  dismiss  the  subject  without 
adverting  to  the  probability  of  the  view  of  Skoda,  that  other 
causes  may  concur  in  producing  the  sounds  of  the  heart;  that,  in 
other  words,  the  aorta  and  the  pulmonary  artery  at  their  origin, 
and  even  the  ventricles  at  times,  may  severally  assist  in  occasion- 
ing both  sounds. 


342  MEDICAL    DIAGNOSIS. 

Examination  of  the  Heart  by  the  Different  Methods  of 
Physical  Diagnosis. 

Before  proceeding  to  examine  the  heart,  we  inquire  into  the 
history  of  the  case,  and  into  such  symptoms  as  the  expression  of 
the  face ;  the  appearance  of  the  eye ;  the  condition  of  the  capillary 
circulation ;  the  presence  or  absence  of  dropsical  swellings  and  of 
cough ;  the  state  of  the  breathing ;  the  character  of  the  pulse ; 
and  the  frequency  and  violence  of  the  palpitations.  By  the  time 
these  points  have  been  ascertained,  the  agitation  arising  from  the 
proposed  exploration  is  somewhat  calmed,  and  the  heart  itself  may 
be  more  advantageously  interrogated.  First,  the  cardiac  region 
is  scrutinized  by  the  eye  and  by  the  hand ;  then  the  size  of  the 
organ  is  estimated  by  percussion ;  and,  lastly,  its  sounds  are  studied 
by  the  stethoscope.  These  different  methods  are  most  conveniently 
practised  when  the  patient  is  in  an  easy  position,  leaning  back  in 
a  chair  or  propped  up  with  pillows  in  bed.  To  examine  them 
more  in  detail : 

INSPECTION. 

Inspection  detects  on  the  chest  of  some  healthy  persons  a  slight 
protrusion  over  the  seat  of  the  heart;  yet  this  is  far  from  being 
constant  or  even  the  general  rule.  When  the  heart  is  hyper- 
trophied,  or  when  fluid  has  accumulated  in  the  pericardium,  we 
perceive  a  marked  prominence  in  the  precordial  region.  A  de- 
pression at  the  lower  part  of  this  region  may  be  natural ;  a  very 
evident  depression  is  almost  always  the  result  of  an  attack  of 
pericardial  inflammation. 

Yet  neither  prominence  nor  depression  is  a  very  important 
sign.  One  much  more  so,  which  inspection  shows,  is  the  impulse 
of  the  heart.  This  is  seen  where  the  apex  beats  against  the  walls 
of  the  chest :  between  the  fifth  and  sixth  ribs,  about  an  inch 
inward  from  the  nipple  and  two  inches  downward.  It  is  for  the 
most  part  confined  to  this  point,  and  appears  as  a  brief  raising 
of  the  integument,  occurring  with  great  regularity  of  succession. 
In  lean  persons  it  is  very  distinct;  in  fat  persons  it  is  generally 
not  at  all  perceptible.  Its  seat,  even  in  those  who  are  in  perfect 
health,  is  not  always  exactly  the  same.  It  is  changed  by  different 
positions,  and  by  the  distention  of  the  stomach  after  a  full  meal 
or  by  flatulence.     It  is  most  modified  by  the  acts  of  respiration. 


DISEASES    OF    THE    HEART.  343 

During  a  long-drawn  inspiration  the  heart  descends  somewhat  and 
the  expanded  lung  sweeps  it  inward,  and  the  impulse  becomes  dis- 
cernible in  the  epigastrium.  During  a  fixed  expiration  the  beat 
moves  upward,  and  appears  more  extended  and  weightier.  The 
changes  produced  in  its  situation  by  disease,  both  thoracic  and  ab- 
dominal, are  many.  It  is  tilted  upward  and  outward  by  the  left 
lobe  of  an  enlarged  liver.  It  is  displaced  by  diverse  aifections  of 
the  lungs  and  pleura.  It  is  forced  up  by  a  pericardial  effusion.  It 
is  visible  lower  down  and  over  a  larger  surface  in  enlargements 
of  the  heart;  but  even  then  it  is  most  distinct  at  the  apex. 

The  alterations  in  the  character  and  force  of  the  impulse  are 
as  diversified  as  those  of  its  seat.  But  they  are  more  readily 
appreciated  by  the  hand  than  by  the  eye. 

PALPATION. 

Palpation  is,  so  far  as  the  exploration  of  the  heart  is  concerned, 
much  preferable  to  inspection.  Many  an  impulse  can  be  felt  which 
cannot  be  seen.  The  rhythm  of  the  motion  is  changed  by  a  large 
number  of  cardiac  affections,  both  functional  and  organic.  So  are 
the  extent  and  force  of  the  beat.  Both  are  temporarily  increased 
by  powerful  excitement;  both  are  permanently  augmented  by 
hypertrophy.  In  dilatation  and  pericardial  effusion,  the  extent 
over  which  the  stroke  is  felt  is  greater  than  in  health ;  but  the 
impulse  is  feeble,  and  in  the  latter  disease  irregular  and  wavy. 
Softening  of  the  texture  of  the  heart,  diseases  of  the  brain,  some 
morbid  states  of  the  blood,  and  a  low  condition  of  the  system  will 
also  enfeeble  the  beat. 

The  hand,  when  laid  on  the  precordial  region,  perceives  at 
times  two  impulses.  This  double  impulse  is  often  recognizable  in 
health,  especially  in  thin  persons.  It  becomes  still  more  evident 
in  hypertrophy  with  dilatation  of  the  ventricles.  One  of  the  beats 
is  systolic;  the  other  corresponds  to  the  diastole.  Bouillaud  cites 
examples  in  which  the  diastolic  stroke  was  double.  The  systolic 
beat  is  occasionally  split  into  several  parts  when  the  pericardium 
adheres  to  the  heart. 

All  these  modifications  of  the  impulse  stand  in  direct  connection 
with  the  action  of  the  ventricles.  The  auricles,  save  in  some  rare 
instances  in  which  they  are  dilated  and  their  walls  thickened,  give 
rise  to  no  perceptible  movement  in  the  chest-wall. 


344  MEDICAL    DIAGNOSIS. 

Besides  the  impulse  of  the  heart,  other  phenomena  may  be 
studied  by  placing  the  hand  over  the  cardiac  region.  The  sounds 
of  the  heart  can  be  analyzed  by  means  of  the  touch.  They  will 
be  felt,  the  one  as  a  long  and  dull,  the  other  as  a  short  and  dis- 
tinct, vibration.  The  motion  is  due  to  the  play  of  the  valves,  and 
disappears  with  their  destruction. 

The  fingers  applied  over  the  heart  perceive  at  times  a  peculiar 
thrill,  or  a  rubbing  movement.  The  first — called  by  Laennec, 
from  its  resemblance  to  the  pur  of  a  cat,  the  purring  tremor — is 
nearly  always  indicative  of  a  valvular  lesion.  The  second  is 
caused  by  the  to-and-fro  motion  of  a  roughened  pericardium. 

A  more  accurate  means  of  studying  the  varying  impulse  than 
is  afforded  by  the  fingers  has  been  sought  to  be  attained  by  instru- 
ments to  record  the  beat  of  the  heart.  The  cardioscope  of  Alison 
was  invented  for  this  purpose,  and  the  ingenious  cardiograph  of 
Marey  has  been  used  for  the  close  analysis  of  the  cardiac  impulse. 
But  as  yet  these  instruments  have  not  proved  to  be  of  real  diag- 
nostic value. 

PERCUSSION. 

Percussion  affords  the  readiest  means  of  judging  of  the  size  of 
the  heart.  But  to  percuss  a  heart  is  not  easy  ;  it  requires  care  and 
some  skill.  The  patient  is  placed  in  a  recumbent  position ;  then, 
by  a  series  of  moderately  strong  taps,  we  proceed  downward  from 
near  the  middle  of  the  left  clavicle,  until  a  dull  sound,  accompanied 
by  decided  resistance,  tells  that  we  are  striking  over  a  solid  organ. 
The  point  at  which  this  dull  sound  begins  is  over,  or  immediately 
at,  the  lower  border  of  the  fourth  cartilage.  It  corresponds  to  the 
upper  limit  of  the  portion  of  the  heart  which  is  left  uncovered  by 
the  lung. 

The  superior  border  of  the  dulness  having  been  thus  ascer- 
tained, we  next  percuss  on  the  right  side  of  the  sternum,  on 
about  a  level  with  the  fifth  rib,  and  progress  across  the  bone. 
At,  or  very  near  to,  its  left  edge  we  find  marked  resistance  and 
a  duller  sound.  Here  we  draw  our  second  line,  and  continue  to 
strike  straight  across  the  cardiac  region  up  to  the  point  at  which  a 
clear,  full  note  demonstrates  that  the  pulmonary  tissue  is  resound- 
ing. This  determines  the  transverse  diameter  of  the  heart;  at 
least  so  far  as  it  can  be  mapped  out  on  the  chest.  The  apex  of 
the  organ  and  its  inferior  surface  remain  to  be  fixed.     The  first  is 


DISEASES    OF    THE    HEART.  345 

readily  done  by  advancing  in  an  oblique  direction  from  the  already 
ascertained  right  border.  But  we  can  save  ourselves  this  trouble 
by  feeling  for  the  impulse  or  by  listening  for  it  with  a  stethoscope. 

The  inferior  surface  is  exceedingly  perplexing  to  circumscribe. 
It  can  be  accomplished  only  by  prolonging  the  line  of  the  dulness 
on  percussion  of  the  upper  border  of  the  liver,*and  then  judging 
by  the  greater  amount  of  resistance  and  the  fall  in  pitch  that  the 
heart  has  been  reached.  These  are  not  easy  to  appreciate ;  nor  is 
it  indeed  often  necessary  to  define  the  contiguous  edges  of  the  left 
lobe  of  the  liver  and  of  the  heart.  If  the  other  boundaries  have 
been  correctly  drawn,  the  size  of  the  heart  can  be  accurately  esti- 
mated,— accurately  enough,  at  least,  for  any  practical  purpose. 
The  dulness  elicited  by  percussing  the  cardiac  region  is  not  so 
absolute  as  that,  of  the  liver  or  of  some  other  solids.  It  is  mixed 
up  with  the  sound  of  the  lung-tissue,  or  with  the  resonance  of  the 
sternum.  Nor  is  it  a  representation  of  the  size  of  the  entire  organ. 
It  simply  portrays  the  more  superficial  portion,  which  is  uncovered 
by  the  lungs. 

In  women  it  is  particularly  difficult  to  define  these  limits.  It 
can  be  done  only  by  having  the  mammary  gland  drawn  to  one  side 
while  percussing.  It  is  equally  difficult  in  children,  as  the  space 
over  wThich  the  dulness  is  perceived  is  very  small.  Indeed,  in 
them  so  unsatisfactory  are  the  results  of  percussion,  that,  were  we 
to  trust  only  to  this  method  of  investigation,  we  should  often  have 
to  conclude  that  the  heart  was  wanting.  In  adults  the  dulness 
ordinarily  spreads  over  two,  or  nearly  two,  intercostal  spaces.  Its 
transverse  diameter  in  a  grown  person  of  medium  size  is  about 
two  inches  and  a  half.  In  tall,  broad-chested  men  it  is  upwards 
of  three  inches.  Such,  at  all  events,  is  the  result  of  measure- 
ments I  have  made.  It  does  not  agree  with  the  statement  of  the 
late  Hughes  Bennett,  that  if,  as  a  general  rule,  the  transverse 
diameter  of  the  dulness  measure  more  than  two  inches,  the  heart 
is  abnormally  enlarged. 

The  range  of  the  dulness  is  changed  by  a  number  of  causes, 
physiological  as  well  as  pathological.  A  full  inspiration  alters  it 
materially,  by  bringing  the  lung  down  over  the  heart,  and  by 
displacing  the  organ  itself.  The  upper  border  of  the  percus- 
sion dulness  shifts  to  the  extent  of  an  intercostal  space.  Below 
the  nipple,  between  the  fifth  and  sixth  ribs,  the  sound  becomes 


346  MEDICAL    DIAGNOSIS. 

clear;  but  over  the  dislodged  lower  part  of  the  heart,  the  beat 
of  which  is  distinctly  seen  under  the  cartilages  of  the  ribs,  at  a 
point  varying  from  three-fourths  to  one  and  a  fourth  inch  from 
the  median  line,  there  is  d ulness  with  resistance  to  the  finger.  A 
full  expiration  produces,  for  the  most  part,  converse  phenomena. 
It  enlarges  the  boundaries,  especially  in  an  upward  and  transverse 
direction.  The  dulness  reaches  nearly,  or  even  entirely,  across  the 
sternum. 

The  area  of  dulness  is  diminished  in  emphysema.  It  is  in- 
creased by  a  shrinking  of  the  left  lung,  and  by  diseases  of  the 
heart  and  of  its  membranes.  Prominent  among  these  stand 
hypertrophy,  dilatation,  and  an  effusion  into  the  pericardial  sac. 

AUSCULTATION. 

When  the  ear  or  a  stethoscope  is  applied  over  a  healthy  heart, 
it  detects  two  sounds  of  very  dissimilar  character:  the  first  is 
long,  dull,  heavy,  and  corresponds  to  the  impulse  against  the 
walls  of  the  chest;  the  second  is  short  and  flapping,  and  occurs 
after  the  impulse.  These  sounds  are  audible  at  all  parts  of  the 
precordial  region,  but  not  everywhere  with  equal  distinctness. 
The  first,  being  more  ventricular  in  origin,  is  best  heard  over  the 
lower  part  of  the  heart ;  the  second,  a  more  strictly  valvular 
sound,  is  more  defined  at  the  base. 

It  has  been  already  stated  that  these  sounds  are,  to  a  great  ex- 
tent, produced  by  the  play  of  the  valves.  Each  of  these  forms  a 
separate  sound,  or  at  least  a  portion  of  one.  Now,  experience 
teaches  that  there  are  points  at  which  the  sounds  of  the  several 
parts  of  the  heart  may  be  isolated.  Some  of  these  points  accord 
with  the  anatomical  seat  of  the  valves;  others  do  not.  None  do 
so  very  closely;  and  the  proximity  of  the  valves  to  one  another  is 
such  as  to  make  it  desirable  that  the  localities  selected  for  listening 
to  them  should  be  some  distance  apart. 

Clinical  observation  sanctions  the  following:  the  sounds  of  the 
aorta  are  to  be  studied  at  the  right  edge  of  the  sternum,  in  the 
second  intercostal  space;  from  there  the  stethoscope  may  be  car- 
ried to  the  second  costal  cartilage  of  the  right  side,  the  "aortic 
cartilage,"  and  down  to  the  left  edge  of  the  sternum  opposite  the 
third  intercostal  space;  that  is,  not  far  from  the  seat  of  the  aortic 
valves.     The  pulmonary  orifice  lies  very  close  to  them ;  but  the 


DISEASES    OF    THE    HEART. 


347 


artery  itself  ascends  to  the  second  costal  cartilage  on  the  left  side. 
Its  sound  may,  therefore,  be  isolated  in  the  second  intercostal 
space,  near  to  the  left  edge  of  the  sternum.  The  mitral  is  listened 
to  immediately  above  the  beat  of  the  apex.     The  sounds  of  the 


Fig.  31. 


Aorlic  valves 


*Pu  lm  otv ary  artery  vcclves 


imfi-trctl 


Diagram  showing  the  points  at  -which  the  separate  valves  may  be  listened  to. 


tricuspid  and  of  the  right  ventricle  may  be  sought  for  in  the 
vicinity  of  and  somewhat  above  the  ensiform  cartilage. 

Both  sounds  are  discerned  at  each  of  these  points.  But  the 
same  sound  varies  in  different  situations.  The  first  sound  over 
the  left  ventricle  near  the  apex  of  the  heart  is  dull,  heavy,  and 


348  MEDICAL    DIAGNOSIS. 

prolonged  ;  that  over  the  right  ventricle  is  clearer,  shorter,  and  of 
higher  pitch.  The  second  sound  heard  there  presents  no  constant 
and  appreciable  variance  from  that  over  the  left  ventricle ;  yet  it  is 
less  ringing  and  distinct  than  the  second  sound  of  the  pulmonary 
artery  and  aorta.  Even  these  two  are  not  precisely  alike.  The 
second  sound  of  the  latter,  when  compared  with  that  of  the 
former,  is  found  to  be  sharper  and  more  accentuated.  The  first 
sound,  however,  does  not  differ  materially  from  that  of  the  pul- 
monary artery.  But  the  first  sound  of  both  does  differ  most 
materially  from  that  over  the  ventricles.  Compared  with  the  first 
sound  over  the  right  ventricle,  the  first  sound  of  the  pulmonary 
artery  is  much  duller,  more  indistinct  and  like  a  vibration,  and 
not  of  so  high  a  pitch.  Compared  with  the  first  sound  at  the 
apex,  the  first  sound  of  the  aorta  lacks  the  weighty,  prolonged 
character  which  belongs  to  the  ventricular  sound. 

These  statements  are  based  on  a  series  of  observations  made, 
some  with  an  ordinary  stethoscope,  some  with  a  double  stetho- 
scope. They  certainly  seem  to  favor  the  view  of  Skoda,  that 
the  first  sound,  as  heard  over  the  great  vessels,  is  not  merely  a 
transmitted  sound,  but  is  one  which  is  partly,  if  not  entirely, 
generated  by  the  arteries  themselves  when  the  blood  rushes  into 
them. 

The  sounds  just  considered  undergo  various  modifications, 
both  when  the  heart  is  affected  and  when  it  is  free  from  disease. 
They  may  be  audible  over  a  larger  space  of  the  chest  than  usual ; 
they  may  be  changed  in  character  and  in  rhythm.  Their  trans- 
mission over  a  larger  space  is  an  unimportant  sign.  They  are 
undoubtedly  perceived  over  a  more  extended  surface  when  the 
heart  is  enlarged;  but  they  are  equally  or  more  diffused  when 
the  surrounding  tissues  are  condensed.  And  even  in  the  most 
perfect  health  their  range  is  very  diversified. 

During  a  full  inspiration,  the  sounds  at  the  interspace  between 
the  second  and  third  costal  cartilages  on  the  left  side  disappear 
almost  entirely,  and  become  faint  at  the  aortic  cartilage.  The 
first  sound  at  the  apex  lessens  also  very  much  in  distinctness,  but 
it  is  better  heard  at  a  new  point  of  impulse,  visible  toward  the 
median  line  and  just  below  the  cartilages  of  the  ribs.  During  a 
full  expiration,  the  extent  over  which  the  heart-sounds  are  per- 
ceived is  increased. 


DISEASES    OF    THE    HEAET.  349 

The  sounds  grow  in  loudness  in  any  functional  disturbance 
of  the  heart.  When  the  organ  is  palpitating  violently  under 
strong  nervous  excitement,  they  may  become  short  and  sharp, 
and  sometimes  so  loud  and  ringing  as  to  be  audible  to  the  by- 
standers. They  are  often  permanently  louder  than  in  health, 
and  are  shorter  and  more  clearly  defined  when  the  walls  of  the 
heart  are  thinned.  This  is  particularly  the  case  with  the  first 
sound.  When  the  walls  of  the  heart  are  thick,  the  first  sound 
over  the  hypertrophied  portion  is  apt  to  be  dull  and  prolonged. 
The  first  sound  is  weakened  if  the  structure  of  the  heart  be  softened : 
hence  it  is  feeble  in  some  low  fevers,  and  in  fatty  degeneration  of 
the  organ.  It  is  also  less  distinct  when  there  is  a  want  of  tone  in 
the  muscle,  or  when  the  mitral  and  tricuspid  valves  are  thickened. 

To  determine  whether  a  dull  first  sound  at  the  apex  be  due  to 
an  injured  mitral  valve,  or  to  an  alteration  of  the  muscular  power 
of  the  heart,  Flint  advises  to  place  the  stethoscope  over  the  apex 
of  the  heart,  and  then  on  the  outside  of  the  left  nipple  to  isolate 
the  element  of  impulsion,  which  unites  with  the  valvular  element 
to  form  the  complex  first  sound.  If  there  be  a  marked  impulsion 
over  the  apex,  but  if  by  means  of  the  stethoscope  placed  to  the 
left  we  perceive  no  sound  at  all  which  possesses  a  valvular  char- 
acter, or  hear  a  sound  which  is  but  faintly  valvular,  we  infer  that 
the  mitral  valves  are  more  or  less  damaged. 

The  second  sound  is  not  so  liable  to  be  changed  as  the  first.  It 
is  rendered  somewhat  duller  by  a  thickening  of  the  semilunar 
valves;  on  the  other  hand,  it  is  more  ringing  when  they  are  thin, 
and  in  great  functional  excitement  of  the  heart,  and  in  altered 
blood  conditions,  as  in  lithiasis  or  in  gout.  The  sound  indeed 
always  becomes  more  distinctly  accentuated  if  the  column  of 
blood  close  the  valves  forcibly.  This  occurs  not  infrequently 
in  hypertrophy  of  the  ventricles.  It  also  takes  place  where  a 
decided  obstruction  exists  to  the  passage  of  blood  through  the 
lungs.  It  is  then  over  the  pulmonary  artery  alone  that  this 
accentuated  second  sound  is  audible. 

Both  the  sounds  are  occasionally  obscure  and  seem  to  arrive 
at  the  ear  from  a  distance.  This  happens  when  fluid  has  ac- 
cumulated in  the  pericardium.  The  sounds  may  be  changed  in 
their  relative  proportion  to  each  other,  and  the  pauses  between 
them  be  lengthened  or  shortened,  or  else  the  sounds  may  intermit 


350  MEDICAL    DIAGNOSIS. 

from  time  to  time.  From  this  perverted  rhythm  we  do  not 
derive  any  definite  instruction  as  to  the  condition  causing  it. 
It  serves  only  to  show  that  the  heart  is  acting  irregularly,  and 
thus  directs  our  attention  to  the  state  of  the  organ.  It  is  apt 
to  be  associated  with  organic  disease;  but  it  can  exist  without 
it.  The  same  may  be  said  of  that  curious  phenomenon,  the 
reduplication  of  the  sounds  of  the  heart.  The  second  sound  is 
the  one  which  is  more  generally  split.  Yet  both  of  them  may 
be  doubled,  or  one  may  be  doubled  over  one  part  of  the  heart 
and  not  over  another ;  so  that  four  or  three  sounds  are  counted 
to  each  beat  of  the  pulse.  The  cause  of  the  reduplication  is, 
as  far  as  we  know,  the  want  of  synchronous  action  of  the  two 
sides  of  the  heart.  The  direct  value  for  diagnosis  of  the  altered 
movement  is  not  great;  but  indirectly  it  teaches  a  most  im- 
portant lesson :  it  tells  us  that  each  side  of  the  heart  forms  its 
own  sounds,  and  that,  to  arrive  at  accurate  conclusions,  each  side 
has  to  be  separately  examined. 

Such,  then,  are  the  modifications  which  the  healthy  sounds 
present.  At  times  we  meet  with  sounds  which  do  not  in  the 
least  resemble  those  naturally  heard,  and  which  overshadow 
them  or  take  their  place.  They  are  called  murmurs,  and  are 
mainly  produced  either  within  the  heart  or  on  its  surface. 

Those  murmurs  which  are  endocardial  have  a  common  quality : 
they  are  more  or  less  blowing.  Yet  the  sound  is  not  always  of 
the  same  character  or  pitch.  It  may  be  low-toned,  it  may  be  high- 
pitched  ;  it  may  be  soft,  it  may  be  harsh ;  it  may  resemble  the 
blowing  of  a  bellows,  it  may  be  musical ;  or  it  may  be  filing,  or 
rasping,  or  sawing.  The  ingenuity  of  every  listener  exerts  itself 
in  tracing  a  similarity  to  some  familiar  noise;  but  all  to  no  prac- 
tical purpose.  These  different  sounds  have  not  been  proved  to 
have  a  significance  beyond  that  of  a  blowing  sound.  They  teach 
us  nothing  certain  as  to  its  source.  They  are,  moreover,  not  at 
all  times  the  same  in  the  same  case,  since  the  heart  when  excited 
may  emit  a  sound  different  from  that  which  it  does  when  it  is 
beating  quietly. 

A  blowing  sound  originates  in  the  altered  relation  of  the  blood 
to  the  part  over  which  it  moves.  This  general  statement  opens 
the  way  to  the  consideration  of  the  specially  acting  elements,  both 
in  the  blood  and  in  the  heart  itself. 


DISEASES    OF    THE    HEAET.  351 

Most  usually  a  cardiac  murmur  springs  from  a  change  at  one 
of  the  orifices.  This  may  be  either  a  narrowing  or  a  roughening, 
which  interposes  a  local  obstruction  to  the  flow  of  the  blood,  or  it 
may  be  an  insufficiency  to  close  the  opening.  In  the  latter  case 
the  blood  regurgitates,  and  a  murmur  is  occasioned  by  the  devia- 
tion of  the  direction  of  the  current  and  the  establishment  of 
another.  This  subversion  of  the  course  of  the  circulating  fluid, 
added  to  its  increased  velocity  and  force,  is  one  of  the  chief  sources 
of  those  temporary  blowing  sounds  not  infrequently  perceived 
when  a  heart  is  violently  excited,  while  both  its  valvular  appa- 
ratus and  its  muscular  texture  are  healthy.  But  we  meet  every 
now  and  then  with  instances  where  none  of  these  causes  are 
present,  and  where  altered  blood  is  the  foundation  of  the  murmur. 

Thus,  to  sum  up  the  subject,  we  find  murmurs  which  depend 
upon  organic  change,  and  murmurs  which  are  unconnected  with 
any  structural  alteration  ;  and  these  inorganic  murmurs  are  due 
either  to  an  unnatural  condition  of  the  blood  or  to  temporarily 
perverted  action  of  the  heart. 

The  murmurs,  however  caused,  have  different  effects  on  the 
sounds  of  the  heart.  They  either  accompany  the  sound  through- 
out the  whole  or  a  part  of  its  duration,  and  thus  obscure  it,  or 
else  they  take  its  place  and  hinder  it  from  being  generated.  In 
time  of  their  occurrence  they  correspond  to  the  contraction  or  to 
the  dilatation  of  the  heart,  and  therefore  to  the  first  or  second 
sound ;  at  least,  they  do  so  as  far  as  we  can  ascertain  practically. 
It  is  true,  they  may  immediately  precede  or  succeed  either,  and 
fill  mainly  the  intervals  of  silence  between  the  sounds ;  but  atten- 
tion to  such  minute  divisions  is,  for  ordinary  purposes,  unneces- 
sary, and  indeed  they  cannot  be  often  readily  recognized  at  the 
bedside.  In  point  of  fact,  it  is  often  difficult  enough  to  say 
whether  the  murmur  we  hear  is  systolic  or  diastolic.  The  readiest 
method  of  judging  of  the  time  of  the  production  of  a  murmur  is 
to  feel  with  the  finger  for  the  impulse  while  listening  with  the 
stethoscope.  The  blowing  sound  which  agrees  with  the  beat  of 
the  heart  is  systolic ;  the  one  between  the  beats  is  diastolic. 

When  a  murmur  is  once  established,  it  attends  each  motion  of 
the  heart  that  can  give  rise  to  it;  but  it  is  not  always  equally 
perceptible.  It  may  become  very  faint,  or  disappear  entirely,  by 
the  patient  changing  his  position.     It  is  sometimes  manifest  only 


352  MEDICAL    DIAGNOSIS. 

when  the  heart  is  acting  strongly.  In  deed,  it  always  requires  a 
certain  force  and  velocity  in  the  passage  of  the  blood,  to  generate 
a  murmur.  Yet  overaction  of  the  heart  may  be  as  destructive  of 
its  distinctness  as  diminished  action.  This  is,  however,  a  matter 
that,  should  it  be  desirable  for  diagnosis,  we  can  control  by  the 
administration  of  medicines  like  digitalis,  aconite,  or  veratrum 
viride,  provided  their  use  be  not  contra-indicated  by  other  con- 
siderations. 

A  murmur  is  sometimes  heard  by  the  patient  himself,  or  is 
audible  before  the  ear  is  placed  over  the  heart.  It  may  be  per- 
ceived as  an  abrupt  blowing  sound,  apparently  coming  out  of  the 
month.  A  gentleman,  whose  mitral  valves  permitted  of  regurgi- 
tation, was  under  my  charge.  "When  he  held  his  breath  and  kept 
his  mouth  open,  he,  as  well  as  I,  could  detect  an  abrupt  blowing 
sound  issuing  from  the  oral  cavity.  This  sound,  when  the  heart's 
action  was  at  all  excited,  accompanied  regularly  each  impulse. 

Posture  exerts  a  decided  effect  upon  murmurs.  A  blowing 
sound  distinct  in  the  recumbent  position  may  become  very  faint 
or  disappear  when  the  patient  stands  erect ;  and  the  reverse  holds 
good,  although  less  common.  The  nature  of  the  murmur — whether 
organic  or  inorganic — does  not  seem  to  influence  the  readiness  with 
which  it  is  affected  by  change  of  posture.*  Pressure,  too,  has  an 
influence  upon  the  abnormal  cardiac  sound  ;  it  notably  augments 
it,  and  often  raises  its  pitch.  Yet  pressing  the  stethoscope  firmly 
against  the  chest  does  not  occasion  as  much  alteration  in  endocar- 
dial as  it  does  in  pericardial  sounds. 

A  murmur  may  be  obscured  by  the  respiratory  sound  ;  but  this 
is  not  apt  to  be  a  cause  of  error  in  diagnosis.  It  is  not  nearly  so 
fruitful  a  source  of  mistake  as  considering  the  natural  sounds  of 
the  lungs  to  be  blowing  sounds  in  the  heart.  Certainlv  the  re- 
semblance  is  often  great;  but  blunders  may  be  readily  avoided  by 
listening  to  the  heart  while  the  patient  suspends  his  breathing. 

Having  ascertained  positively  the  existence  and  the  time  of 
occurrence  of  an  endocardial  murmur,  the  next  thing  is  to  deter- 
mine its  exact  seat,  and,  if  possible,  its  immediate  cause.     The 

*  Anaemic  murmurs  are  supposed  to  be  most  affected  by  position  ;  and  Dr. 
James  H.  Hutcbinson  (Amer.  Journ.  uf  Med.  Sci.,  April,  1872)  believes 
that  their  being  much  more  intense  in  the  recumbent  posture  is  a  differential 
cbaracteristic  of  importance. 


DISEASES    OF    THE    HEART.  353 

seat  of  the  murmur  is  judged  of  by  the  place  of  its  greatest  in- 
tensity, and  by  the  relation  this  bears  to  one  of  the  four  points  for 
the  clinical  examination  of  the  heart  above  described.  If  it  be 
most  distinct  at  or  near  the  apex  of  the  heart,  it  is  produced  at 
the  mitral  orifice;  if  immediately  above  or  at  the  ensiform  car- 
tilage, it  is  generated  in  the  right  ventricle  and  at  the  tricuspid 
opening.  If  we  hear  it  most  plainly  at  the  sternum,  somewhat 
toward  its  left  border  on  a  level  with  the  third  intercostal  space  or 
even  the  fourth  rib,  and  with  equal  or  nearly  equal  distinctness 
at  the  second  costal  cartilage  on  the  right  side,  we  are  enabled  to 
decide  that  it  is  developed  at  the  origin  of  the  aorta.  The  pul- 
monary artery  is  not  often  the  seat  of  a  murmur.  When  it  is, 
this  is  clearly  perceptible  in  the  second  intercostal  space  on  the  left 
side,  and  extends,  if  the  valves  be  diseased,  to  the  junction  of  the 
third  left  cartilage  with  the  sternum ;  although  we  must  bear  in 
mind  that  occasionally  in  mitral  affections  the  murmur  is  loudest 
in  the  pulmonary  area,  or,  as  Naunyn  has  shown,  not  exactly 
over  the  artery,  but  rather  an  inch  and  a  half  or  more  from  the 
left  edge  of  the  sternum  in  the  second  interspace. 

Any  of  these  situations  may  be  the  site  of  a  distinct  murmur 
occupying  only  one  sound  of  the  heart,  or  being  produced  in  both, 
— one  murmur  taking  place  with,  the  other  against,  the  current  of 
blood.  Yet  it  rarely  happens  that  the  murmur  is  strictly  limited 
to  one  of  these  positions :  it  will  mostly  extend  in  various  direc- 
tions from  its  point  of  intensity,  growing  fainter  and  fainter  as 
this  is  left.  A  blowing  murmur  thus  transmitted  may  drown  the 
natural  sounds  of  the  heart  at  the  parts  not  diseased.  But  when 
one  orifice  only  is  affected,  we  can  usually  hear  the  sounds  at  the 
other  valves.  They  may  be  obscured,  but  still  they  exist ;  and  it 
is  a  vast  aid  when  they  are  heard,  since  they  set  the  limits  to  the 
disease.  How  important  is  it,  then,  to  examine  each  portion  of 
the  heart  separately,  as  much  for  the  purpose  of  saying  what  is 
not  as  what  is  deranged  ! 

If  satisfied  as  to  the  seat  of  the  murmur,  we  naturally  turn  to 
inquire  into  its  origin.  Is  it  caused  by  an  alteration  of  the  valves  ? 
Is  it  unconnected  with  any  appreciable  change  of  structure  in  the 
heart?  There  is  nothing  in  the  murmur  itself  which  will  tell  us 
positively.  As  a  rule,  it  is  true  that  a  harsh  murmur  results  from 
organic  disease,  and  a  soft  murmur  is  inorganic;  but  we  judge 

23 


354  MEDICAL    DIAGNOSIS. 

with  much  more  certainty  by  the  time  of  the  occurrence  of  the 
blowing  sound  and  by  the  accompanying  phenomena.  A  murmur 
attending  the  distention  of  the  ventricles  shows  that  the  orifices 
are  injured.  A  systolic  murmur  may  be  either  organic,  or  it  may 
indicate  simply  a  change  in  the  state  of  the  blood,  or  of  the  force 
and  velocity  with  which  it  is  circulating.  In  the  latter  case,  how- 
ever, the  abnormal  sound  is  temporary,  and  disappears  with  the 
excitement.  If  arising  from  an  impoverished  state  of  the  blood, 
it  is  generally  soft,  of  low  pitch,  is  perceived  over  the  base  of  the 
heart,  and  is  accompanied  by  a  humming  sound  in  the  veins  of 
the  neck.  It  may  be  heard  over  the  right  base,  or  on  the  left 
side  over  the  pulmonary  artery;  although  Balfour  maintains  that 
it  is  not  really  over  the  pulmonary  artery,  but  about  half  an  inch 
or  more  to  the  left  of  the  pulmonary  area,  and  is  not  an  arterial, 
but  an  auricular  sound. 

Throughout  the  consideration  of  the  endocardial  murmurs,  they 
have  been  treated  as  originating;  at  the  seat  of  the  valves.  In 
truth,  it  is  there  that  they  are  formed.  Still,  they  are  occasionally 
due  to  morbid  states  in  the  body  of  the  ventricle,  or  in  the  auricle. 
But  in  either  case,  then,  they  are  clinical  curiosities.  As  regards 
the  auricles,  they  yield  no  appreciable  sound  in  health,  nor  are 
they  in  disease  but  rarely  the  source  either  of  sound  or  of  murmur. 

A  blowing  sound  is  not  of  necessity  limited  to  the  heart:  it 
may  be  transmitted  all  over  the  arterial  system.  Yet  it  would 
be  a  great  mistake  to  suppose  that  every  murmur  heard  over  the 
arteries  is  connected  with  a  disease  of  the  heart.  It  is  often  but 
the  sign  of  impoverished  blood,  or  a  sound  dependent  upon  local 
roughening  or  narrowing  of  the  tube.  The  latter  may  be  tem- 
porarily produced  by  the  pressure  of  a  stethoscope, — a  fact  of 
which  it  is  well  to  be  aware.  It  is  even  stated  that  pressure  over 
a  healthy  heart  may  generate  a  murmur;  but  I  confess  that  I 
have  never  been  able  to  satisfy  myself  of  the  truth  of  this  state- 
ment. It  is  certainly  incorrect  as  a  general  rule,  and  depends, 
when  it  happens,  more  likely  upon  the  condition  of  the  blood  and 
the  force  with  which  it  circulates. 

Let  us  now  examine  the  sounds  which  originate  on  the  outside 
of  the  heart.  These  pericardial  murmurs  have  all  a  common 
source:  they  all  result  from  irregularities  on  the  membrane. 
Like  the  pleura,  the  smooth  serous  covering  of  the  heart  moves 


DISEASES    OF    THE    HEART.  355 

noiselessly  in  health ;  but  when  it  is  roughened  by  a  deposit  of 
any  kind,  the  friction  of  its  surfaces  gives  rise  to  a  sound  which 
may  be  single,  but  which  is  usually  double.  The  character  of 
this  sound  is  variable.  It  may  be  a  to-and-fro  rubbing  murmur, 
or  it  may  be  grazing,  or  scratching,  or  creaking,  or  whistling,  or 
clicking  and  resembling  the  valvular  sounds.  It  has  but  one 
quality  which  is  constant,  and  that  is,  its  superficiality.  By  this 
superficiality ;  by  the  strict  limitation  of  the  sound  to  the  region 
of  the  heart;  by  its  altering  from  time  to  time  its  precise  seat; 
by  its  greater  extent  and  intensity  when  the  patient  bends  for- 
ward ;  by  its  occasional  increase,  and  even  change  of  character,  on 
external  pressure;  by  its  following,  rather  than  occurring  with, 
the  movements  of  the  heart;  and  by  the  sensation  of  friction 
which  it  communicates  to  the  finger, — we  know  that  the  sound 
heard  is  produced  on  the  surface,  and  not  in  the  inside,  of  the 
heart.  Yet,  in  spite  of  this  array  of  points  of  difference,  it  is  often 
difficult  to  distinguish  a  pericardial  from  an  endocardial  murmur. 

One  of  the  sources  of  error  not  easy  at  times  to  avoid  is  caused 
by  the  failure  to  discriminate  between  the  presystolic  apex  mur- 
mur, now  regarded  universally  as  characteristic  of  mitral  con- 
striction, and  a  pericardial  friction  localized  near  the  apex.  The 
only  trustworthy  points  of  distinction  are  that  the  pericardial 
sound  changes  in  its  quality  and  loudness,  and  that  it  is  ren- 
dered stronger  and  altered  in  pitch  by  pressure  exerted  with  the 
stethoscope. 

A  friction  sound  is  prone  to  mask  the  natural  sounds  of  the 
heart.  At  times,  although  heard  over  the  cardiac  region,  it  is  not 
due  to  inflammation  of  the  pericardium.  The  exudation  may  be 
on  the  surface  of  the  pleura  adjacent  to  the  pericardium,  and  the 
murmur  be  caused  solely  by  the  movements  of  the  heart.  Some- 
times, again,  the  sound  heard  in  the  cardiac  region  is  in  reality 
the  rubbing  of  an  inflamed  pleura.  If  any  doubt  exist,  let  the 
patient  be  told  to  suspend  his  breathing.  As  this  is  stopped,  the 
pleural  sound  ceases. 

Such  is  a  brief  description  of  the  different  physical  signs  met 
with  in  examining  the  heart,  both  in  health  and  in  disease.  Their 
importance  for  diagnosis  it  is  difficult  to  overestimate.  A  knowl- 
edge of  the  physical  signs  is  the  solid  foundation,  without  which 
any  structure  that  may  be  raised  will  soon  tumble  to  pieces. 


356  MEDICAL    DIAGNOSIS. 

The  General  and  Local  Symptoms  of  Diseases  of  the  Heart. 

It  is  not  easy  to  say  what  are  and  what  are  not  the  symptoms 
that  belong  to  diseases  of  the  heart.  There  are  vital  manifestations 
directing  attention  to  the  heart  which  are  not  associated  with  any 
change  in  its  structure ;  and  most  serious  changes  in  its  structure 
may  occur  without  any  of  these  vital  manifestations.  Yet  we  often 
find  a  significant  group  of  symptoms  which  accompany  an  affection 
of  the  heart.  Some  of  these  attest  directly  the  organ  disturbed, 
such  as  pain  in  the  cardiac  region,  and  palpitation.  Others  are  the 
indirect  and  more  remote  expressions  of  its  derangement,  such  as 
cough,  dyspnoea,  hemorrhages,  dropsy,  disorders  of  the  brain  and 
nervous  system,  engorgement  of  the  abdominal  viscera,  a  peculiar 
state  of  the  arteries  and  veins,  and  the  aspect  of  the  face.  It  is 
unnecessary  to  do  more  than  mention  some  of  these,  since  several 
have  been  already  described  in  connection  with  pulmonary  com- 
plaints, and  there  is  nothing  in  the  cough  or  in  the  shortness  of 
breath  by  which  we  can  absolutely  determine  it  to  be  caused  by  a 
disease  of  the  heart.  The  same  with  respect  to  the  hemorrhage ; 
there  is  nothing  characteristic  about  it.  It  simply  proves  the  efforts 
of  the  blood-vessels  to  relieve  themselves  of  the  strain  which  the 
disturbance  in  the  flow  of  the  blood  has  put  on  them.  The  capil- 
laries and  the  smaller  blood-vessels  give  way  first ;  partly  from  the 
reason  just  assigned,  and  partly  from  the  altered  state  of  their  nu- 
trition, which  a  disordered  circulation  brings  in  its  train.  These 
hemorrhages  are  prone  to  happen  from  the  bronchial  tubes  and  the 
lungs,  and  the  blood  is  expectorated  ;  but  they  may  also  take  place 
directly  into  the  pulmonary  tissue,  or  into  or  from  any  part  of  the 
body.  Their  danger  is  in  proportion  to  the  amount,  to  the  im- 
portance of  the  function  of  the  structures  into  which  the  blood  is 
effused,  and  to  the  possibility  of  its  finding  an  outlet.  It  is  hardly 
requisite  to  state  that  the  peril  is  greatest  when  the  circulating  fluid 
has  been  poured  out  into  the  brain. 

Cardiac  Dropsy. — The  dropsy  caused  by  a  disease  of  the 
heart  is  met  with  in  different  situations:  in  the  cellular  tissues, 
in  the  peritoneal  and  pleural  cavities,  in  the  pericardium,  in  the 
ventricles  of  the  brain,  and  under  the  arachnoid,  in  the  air-cells 
of  the  lungs, — in  fact,  in  any  part  where  fluid  can  exude,  and 
where  there  is  a  space  which  can  receive. 


DISEASES    OP    THE    HEART.  357 

In  anasarca  dependent  upon  a  cardiac  lesion,  the  dropsical 
swelling  begins  about  the  ankles  and  feet :  hence  oedema  starting 
in  this  situation  is  regarded  as  among  the  surest  of  the  symptoms 
of  a  disease  of  the  heart.  The  accumulation  is  much  influenced 
by  position :  the  feet  are  more  puffy  toward  evening,  when  the 
patient  has  been  all  day  iu  the  erect  posture,  and  least  so  when 
he  gets  up  in  the  morning. 

What  the  condition  of  the  heart  is  that  gives  rise  to  dropsy, 
has  been  made  a  matter  of  much  dispute.  It  has  been  held  to  be 
uniformly  connected  with  dilatation  of  the  right  side  of  the  heart. 
It  has  been  thought  not  to  happen  unless  a  tricuspid  regurgitation 
be  also  present.  It  has  been  taught  to  be  invariably  linked  to  a 
valvular  affection.  Clinical  experience  shows  us  that  it  may  or 
may  not  exist  where  these  states  are  present.  The  dropsy  is  most 
constantly  found  to  be  associated  with  an  impediment  to,  or  dis- 
turbance in,  the  flow  of  the  venous  blood,  and,  therefore,  with 
disorder  of  the  right  side  of  the  heart,  particularly  with  a  dilata- 
tion of  the  cavities.  It  may  be  permanent  or  not.  Its  extent 
certainly  does  not  bear  a  constant  relation  to  the  extent  of  the 
cardiac  disease.  It  bears  a  more  constant  relation  to  the  amount 
of  venous  congestion,  and  to  the  impoverishment  of  the  blood. 

Derangement  of  the  Circulation. — Unmistakable  evi- 
dence of  the  obstruction  to  the  flow  of  the  blood  through  the 
veins  is  afforded  by  their  prominence  in  different  portions  of  the 
body.  This  is  especially  manifest  in  the  superficial  veins  of  the 
neck,  which,  moreover,  when  the  tricuspid  orifice  is  permanently 
open,  exhibit  a  distinct  pulsation  with  each  beat  of  the  heart. 
The  turgid  condition  of  the  venous  system  is  rendered  equally 
obvious  by  the  livid  tinge  of  the  skin  and  the  bluish  color  of  the 
lip,  and  by  those  ramifications  of  fine  bluish  vessels  which  strike 
the  eye  at  once.  But  the  arterial  system  may  also  be  gorged,  and 
we  may  find  the  capillaries  and  the  smaller  arteries  seemingly 
ready  to  burst.  The  conjunctiva  is  then  highly  injected,  and 
the  cheek  has  a  coarse,  red  look.  This  change  in  the  color  and 
appearance  of  the  face,  the  thickening  of  the  eyelids,  and  the 
prominent  eye,  make  up  the  peculiar  physiognomy  of  a  chronic 
cardiac  malady.  The  state  of  the  larger  arteries  is  very  variable, 
and  mainly  according  to  the  nature  of  the  disorder.  The  pulse 
may  be  small  and  tense ;  it  may  be  full ;  it  may  be  rebounding ; 


358  MEDICAL    DIAGNOSIS. 

it  may  be  very  irregular;  and  it  is  often  out  of  all  proportion  to 
the  forcible  action  of  the  heart.  But  these  are  matters  to  which 
we  shall  return. 

The  derangement  of  the  circulation  of  individual  parts  mani- 
fests itself  by  special  symptoms.  It  shows  itself  in  the  brain  by 
violent  headaches,  by  vertigo,  by  apoplectic  seizures.  We  see  evi- 
dences of  the  congestion  of  the  nervous  system  in  the  disturbed 
dreams ;  in  the  sudden  starting  up  from  sleep ;  in  the  irregular 
action  of  certain  muscles;  in  the  spots  which  float  before  the  eye. 
It  is  possible  that  the  strange  sense  of  insecurity,  and  the  irrita- 
bility, of  which  patients  afflicted  with  a  cardiac  malady  complain, 
are  produced  by  the  same  cause.  At  any  rate,  whether  produced 
thus  or  not,  they  are  remarkable  symptoms.  There  is  no  disease 
which  unnerves  more  than  a  disease  of  the  heart.  Indeed,  mere 
fear  of  its  presence  gives  rise  to  restlessness  and  gloom,  and 
breeds  timidity  in  those  who  would  look  any  external  danger 
boldly  in  the  face. 

The  disordered  flow  of  blood  through  the  abdominal  viscera 
occasions  organic  changes  and  a  disturbance  of  the  functions  of 
the  several  organs.  Thus,  the  liver  increases  in  size,  or  undergoes 
other  alterations  which  interfere  more  or  less  seriously  with  the 
elimination  of  the  bile;  or  the  kidneys  no  longer  secrete  as  in 
health,  but  drain  off  the  albumen  of  the  blood,  and  finally  pass 
into  a  state  of  disorganization;  or  the  spleen  sustains  textural 
transformations.  These  states  all  tend  to  give  rise  to  more  and 
more  dropsy,  and  hence  to  more  and  more  suffering. 

The  symptoms  which  point  most  directly  to  the  heart  itself  are 
palpitation  and  irregularity  of  action,  and  pain.  These  symptoms 
imply  that  the  function  of  the  organ  is  disturbed,  or  that  its  in- 
nervation is  in  some  manner  deranged ;  but  they  imply  nothing 
more.  They  are,  therefore,  common  to  functional  derangement 
which  occurs  associated  with  structural  changes  in  the  heart,  and 
to  purely  functional  derangement. 

Cardiac  Pain. — Pain  in  or  over  the  heart  is  met  with  both  in 
acute  and  in  chronic  diseases ;  yet  it  is  not  a  regular  or  well-defined 
symptom  of  either.  When  we  reflect  that  the  heart  may  be  pinched, 
may  be  torn,  without  exciting  any  suffering,  it  will  be  readily  un- 
derstood why  its  disorders  do  not  occasion  much  pain.  Indeed, 
many  a  case  of  enormous  enlargement  of  the  heart,  or  of  profound 


DISEASES    OF    THE    HEART.  359 

textural  alteration  of  its  walls  or  valvular  apparatus,  is  unaccom- 
panied by  pain.  Still,  we  meet  with  instances  in  which  distress  at 
the  heart  and  various  uneasy  sensations  are  among  the  more  marked 
symptoms  of  a  chronic  cardiac  lesion ;  and  we  even  find  persons 
complaining  of  a  persistent  pain  in  the  heart,  which  extends  to 
the  left  side  of  the  neck  and  arm,  in  whom  this  symptom  has 
preceded  the  signs  of  a  disease  of  the  heart  or  of  its  great  vessels. 

In  the  acute  cardiac  affections  pain  is  a  not  inconstant  symptom. 
Uneasy  sensations,  not  amounting  perhaps  to  absolute  pain,  are 
complained  of  in  endocarditis.  Actual  pain  is  among  the  vital 
manifestations  of  inflammation  of  the  substance  of  the  heart,  and 
of  the  pericardium.  In  the  latter  disorder  it  is  usually  increased 
by  pressure,  and  is  frequently  very  severe.  But  no  suffering  is 
so  harrowing  as  that  which  happens  in  the  obscure  malady  termed 
angina  pectoris. 

Angina  Pectoris. — Although  the  nature  of  this  complaint  may 
be  hidden,  the  symptoms  are  obvious  enough.  We  do  not  know 
what  the  precise  causes  of  this  angina  are ;  but  we  do  know  that 
the  disease  occasions  paroxysms  of  the  most  intolerable  anguish. 
These  paroxysms  come  on  suddenly,  and  pass  off  as  suddenly. 
Their  main  feature  is  an  agonizing  pain  in  the  prsecordia,  as  if 
the  heart  were  being  firmly  grasped  by  an  invisible  hand,  or  as  if 
it  were  being  torn  to  pieces.  The  pain  is,  however,  not  limited 
to  the  cardiac  region;  it  radiates  in  various  directions,  shooting  to 
the  back,  to  the  neck,  and  especially  down  the  left  arm.  But  this 
is  not  all:  worse  than  the  pain  are  the  intense  anxiety  and  the 
feeling  of  impending  death.  The  heart  palpitates  during  the  fit; 
yet,  if  we  judge  by  the  character  of  the  pulse,  its  movements  are 
not  always  materially  disturbed.  The  beat  of  the  artery  at  the 
wrist  may  be  small,  may  be  weak,  may  be  irregular,  may  be  accel- 
erated; but  it  may  also  be  full,  strong,  regular,  yet  not  increased 
in  frequency;  again,  there  may  be  a  decided  difference  between  the 
pulses,  the  left  being  almost  or  quite  imperceptible.*  The  face  is 
generally  pale.  Difficulty  in  breathing,  contrary  to  what  might 
be  expected,  is  not  a  prominent  symptom,  and  is,  in  fact,  often 
wanting,  while  sometimes  the  breathing  is  irregular  and  of  the 
"  Cheyne-Stokes"   variety.      Giddiness,  spasmodic  seizures,  tem- 

*  Hamilton  Osgood,  Amer.  Journ.  of  Med.  Sci.,  Oct.  1875. 


360  MEDICAL    DIAGNOSIS. 

porary  coma,  perverted  sensibility,  occasionally  attend  or  follow 
the  cardiac  attack. 

The  duration  of  the  fits  is  as  uncertain  as  are  the  causes  which 
excite  them.  They  may  cease  in  a  few  minutes ;  they  may  last 
upward  of  an  hour.  They  come  on  rapidly,  without  any  assign- 
able reason;  they  are  reproduced  by  bodily  ailment,  or  by  exertion, 
by  fatigue,  by  exposure  to  cold,  or  by  mental  irritation.  How- 
ever provoked,  they  are  always  dangerous.  The  heart  may  stop 
beating  during  the  paroxysm.  "  My  life  is  in  the  hands  of  any 
rascal  who  chooses  to  annoy  and  tease  me,"  was  a  saying  of  John 
Hunter.  And  in  truth,  after  he  had  suffered  for  years  from  these 
seizures,  his  ungovernable  temper  brought  on  one  in  which  he  ex- 
pired. It  happens  sometimes  that  the  second  attack  follows  at  a 
short  interval  the  one  by  which  the  disease  first  declares  itself,  and 
proves  fatal.  Latham*  narrates  the  history  of  two  cases  of  this 
kind.  In  one,  life  ceased  in  a  fortnight  after  the  first  seizure; 
in  the  other,  in  ten  days.  Nay,  it  may  be  cut  short  even  in  the 
midst  of  the  first  manifestation  of  the  malady.  Such  was  the 
death  of  Arnold  of  Rugby. f 

The  immediate  conditions  on  which  the  symptoms  of  the  attack 
depend  are  veiled  in  obscurity.  Whether  they  be  or  be  not  pro- 
duced by  a  temporary  increase  of  weakness  in  an  already  enfeebled 
organ ;  whether  a  cardiac  spasm  occur  or  do  not  occur ;  whether 
the  pain  and  the  sensation  of  approaching  death  be  or  be  not  caused 
by  an  acute  distention  of  the  heart  with  blood, — we  do  not  know. 
All  we  do  know  positively  is,  that  the  excessive  pain  abruptly  ap- 
pearing and  disappearing  points  to  what  we  are  content  to  call 
deranged  innervation.  Yet  we  can  go  a  step  further;  we  can  say 
with  certainty  that  angina  pectoris  is  seldom  an  uncomplicated 
nervous  disease.  Modern  research  has  taught  us,  or,  to  speak  more 
guardedly,  has  rendered  it  more  than  highly  probable,  that  these 
so-called  spasms  of  the  heart,  or  outbreaks  of  a  cardiac  neurosis, 
as  angina  is  now  so  commonly  supposed  to  be,  are  nearly  always 
linked  to  some  structural  change.  This  structural  change,  so  far 
as  we  can  now  see,  is,  however,  not  at  all  times  the  same.  The 
list  of  disorders  of  the  heart  and  arteries  which  angina  pectoris 

*  Lectures  on  Diseases  of  the  Heart,  vol.  ii. 

f  Stanley,  Life  and  Correspondence  of  Thomas  Arnold. 


DISEASES    OP    THE    HEART.  361 

may  accompany  is  indeed  very  long.  There  is  hardly  an  affection 
of  the  walls  or  cavities  of  the  heart,  scarcely  a  morbid  condition 
of  the  arteries  that  nourish  it  or  spring  from  it,  with  which  the 
distressing  malady  has  not  been  observed  to  be  associated.  It  has 
been  found  as  an  attendant  on  ossification  of  the  coronary  artery ; 
on  every  form  of  valvular  disease;  on  thinning  of  the  parietes  of 
the  heart ;  on  their  fatty  softening;  on  fungoid  growths  springing 
from  the  apex  of  the  organ.*  It  has  been  thought  that  combined 
with  all  of  these  states  is  fatty  degeneration,  which  thus  would  be 
at  the  root  of  the  angina.  Such  is  the  opinion  of  Watson,  and 
such  would  also  seem  to  be  the  result  of  the  observations  of  Quain.f 
"Whether  this  view  be  correct  or  not,  it  is  undoubted  that  fatty 
degeneration  is  more  frequently  conjoined  with  angina  than  is  any 
other  organic  disease.  Yet  fatty  degeneration  occurs  often  without 
angina,  and  we  are  thus  forced  to  admit  that,  however  frequent 
the  association,  some  unknown  element  is  still  here,  as  in  all  other 
cases,  the  determining  cause. 

Angina  pectoris  is  easy  of  recognition.  The  points  to  ascertain 
in  diagnosis  are,  whether  it  is  linked  to  an  organic  cause,  and  to 
what  organic  cause,  or  whether  it  is  a  pure  neurosis,  either  primary 
or  reflected.  Yet  it  may  be  a  question  whether  those  severe  pains 
in  the  region  of  the  heart,  which  occur  in  feeble  anaemic  persons 
after  unaccustomed  exertion,  or  which  are  brought  on  bv  the 
excessive  use  of  tobacco,*  or  which  happen  in  rheumatic  or  gouty 
subjects,  especially  while  suffering  from  indigestion,  are  real 
angina,  or  whether  they  may  be  separated  from  this  affection. 
They  differ  from  it,  irrespective  of  being  far  less  violent  and  less 
radiating,  by  the  circumstances  leading  to  an  attack,  and  by  their 
constant  association  with  palpitation.  Intercostal  neuralgia  with 
palpitation  might  be  mistaken  for  angina ;  but  the  painful  spots 
in  the  course  of  the  affected  nerve,  and  the  comparatively  slight 
suffering,  distinguish  it.  In  truth,  it  is  a  complaint  seated  only  in 
the  thoracic  walls,  and  referred  by  the  patient  to  the  heart.  Great 
irritability  of  the  heart,  attended  with  pain,  due  perhaps  to  neu- 


*  B.  Travers,  Medico-Chirurgical  Transactions,  vol.  xvii. 
f  Medico-Chirurgical  Transactions,  vol.  xxxiii. 

%  Beau,  Journal  de  Medecine  et  Chirurgie,  July,  1862;  Eulenberg,  "  An- 
gina,,:  in  Ziemssen's  Cyclopedia. 


362  MEDICAL    DIAGNOSIS. 

ralgia  of  the  cardiac  plexus,  is  discriminated  from  true  angina  by 
the  palpitations,  and  by  their  connection  with  pain  which  never 
rises  to  the  anguish  of  angina  pectoris.  Often,  too,  this  apparent 
or  false  angina  is  found  in  persons  who  are  subject  to  neuralgia, 
or  who  are  laboring  under  a  disorder  of  one  of  the  abdominal 
viscera,  and  is  then  clearly  reflex.  It  must,  however,  be  admitted 
that  the  distinction  between  true  and  false  angina  is  rather  one  of 
degree  than  of  kind  ;  for  the  cardiac  plexus  is  precisely  the  point 
particularly  involved  in  angina,  and  it  is  now  generally  thought 
that  the  disturbance  of  the  heart  in  this  painful  malady  occurs 
through  the  influence  of  the  sympathetic  fibres  which  meet  in  the 
plexus,  and  that  there  is,  as  has  been  so  ably  demonstrated  by 
Brunton,  a  vaso-motor  spasm  of  the  small  vessels  with  a  rise  in 
blood-pressure  in  the  arteries  of  the  system. 

Another  trouble  that  may  be  confounded  with  angina  is  what 
may  be  called  cardiac  epilepsy.  In  this  rare  affection  intense 
pain  in  the  region  of  the  heart  happens  in  paroxysms.  But 
unconsciousness,  however  temporary,  occurs  also,  and  the  pain 
is  apt  to  follow  rather  than  to  precede  the  unconsciousness. 
Yet  it  may  outlast  it,  and  become  associated  with  twitching  of 
the  muscles  of  the  face  and  with  other  spasmodic  movements. 
These,  the  unconsciousness,  and  the  time  at  which  the  pain 
happens,  distinguish  the  malady  from  those  instances  of  angina 
in  which,  owing  to  the  severity  of  the  pain,  the  patient  passes 
into  a  protracted  faint. 

Palpitation. — This  arises  in  various  diseases  of  the  heart.  It 
happens  at  the  beginning  of  acute  affections;  it  is  an  unfailing 
accompaniment  of  some  chronic  lesions.  It  is  especially  dis- 
tressing when  the  cavities  are  dilated  and  the  walls  of  the  organ 
thinned.  But  it  bears  no  positive  relation  to  any  special  cardiac 
malady,  and  is  therefore  not  diagnostic  of  any.  So,  too,  with 
irregular  rhythm  of  the  heart's  action,  with  which  palpitation  is 
in  truth  often  combined.  It  tells  us  nothing  more  than  that  the 
regular  movements  of  the  heart  are  disarranged.  Frequently  this 
disarrangement  is  due  to  a  serious  change  in  the  valves  or  in  the 
muscular  structure.  But  palpitation,  with  or  without  irregular 
rhythm,  may  take  place  in  a  perfectly  sound  heart, — sound,  at 
least,  so  far  as  our  means  of  investigation  enable  us  to  determine. 

Often  the  pulsations  of  the  heart  become  stronger,  more  exten- 


DISEASES    OF    THE    HEART.  363 

sive,  and  more  perceptible,  from  mere  nervous  excitement.  But 
it  is  not  necessary  to  detail  the  symptoms  of  a  purely  nervous  pal- 
pitation. Every  one  has  experienced  them.  Every  one  knows 
that  there  is  a  feeling  of  slight  constriction  about  the  chest,  with 
a  hurried  breathing,  and  a  strange  sensation  as  if  the  heart  were 
leaping  from  its  place.  Every  one  is  also  aware  that  the  organ 
is  felt  thumping  against  the  walls  of  the  chest,  and  with  a  force 
which  shakes  them.  The  popular  notion,  that  the  heart  is  the 
seat  of  the  emotions,  is  based  on  these  striking  evidences  of  its 
disturbed  action,  and  poets  have  seized  upon  and  delineated  with 
accuracy  some  of  the  even  more  strictly  physical  phenomena  of 
the  extended  impulse  under  strong  nervous  excitement.  Thus, 
the  great  dramatist,  in  the  "  Rape  of  Lucrece,"  says  : 

"His  hand,  that  yet  remains  upon  her  breast 
(Rude  ram  to  batter  such  an  ivory  wall !), 
May  feel  her  heart,  poor  citizen,  distressed, 
"Wounding  itself  to  death,  rise  up  and  fall, 
Beating  her  bulk,  that  his  hand  shakes  withal." 

But,  apart  from  the  increase  of  the  beat  by  mere  temporary 
agitation,  a  heart  may  act  overfrequently  and  overstrongly  and 
its  action  become  sensible  to  the  person,  in  other  words,  it  may 
palpitate,  from  some  more  unremitting  excitement  dependent 
upon  perverted  innervation.  This  is  the  main  cause,  as  we  shall 
presently  see,  of  the  altered  impulse  of  the  heart  in  the  so-called 
functional  disorders. 

FUNCTIONAL   DISORDERS   OF  THE   HEART. 

It  has  just  been  stated  that  the  direct  symptoms  of  a  cardiac 
disorder — pain,  palpitation,  irregular  action — are  met  with  when 
no  recognizable  structural  change  has  taken  place.  Under  such 
circumstances  the  affection  of  the  heart  is  termed  functional,  and 
its  symptoms  are  those  already  mentioned,  variously  combined, 
sometimes  the  one  predominating,  sometimes  the  other.  These 
functional  disorders  are  very  much  more  frequent  than  the  organic. 
They  are,  for  the  most  part,  produced  by  direct  excitement  of  the 
heart,  or  by  its  being  sympathetically  disturbed  by  some  source 
of  irritation  existing  remote  from  it,  or  in  the  system  at  large. 
The  symptoms  may  be  said  to  constitute  the  disease.     As  they 


364  MEDICAL    DIAGNOSIS. 

have  been  above  examined  separately  in  connection  chiefly  with 
organic  affections,  they  may  be  here  examined  separately  in  con- 
nection chiefly  with  functional  derangements.  And  as  in  the 
former,  so  in  the  latter,  one  symptom  is  apt  to  attend  the  other. 

Disorders  characterized  by  Palpitation,  associated  or  not  with 
Change  of  Khythm, 

We  have  already  briefly  alluded  to  the  causes  of  augmented 
action  which  are  associated  with  organic  changes,  and  to  those 
which  occasion  temporary  disturbance  of  the  heart.  A  more 
lasting  form  of  palpitation  is  engendered  when  the  organ  is  kept 
constantly  excited  by  a  deranged  condition  of  some  viscus  re- 
mote from  it;  by  the  use  of  stimulating  substances;  or  by  some 
general  morbid  states.  Thus,  a  disordered  stomach  or  liver  leads 
to  a  reflex  disturbance  of  the  heart,  which  ceases  if  the  disorder 
of  the  stomach  or  liver  be  remedied.  In  gouty  and  rheumatic 
persons  the  heart  frequently  pulsates  with  increased  quickness 
and  violence,  and  sometimes  with  marked  irregularity.  Special 
articles  of  diet,  especially  tea  or  coffee,  produce  palpitation  ;  so  does 
the  inordinate  use  of  tobacco.  Masturbation  and  excessive  sexual 
indulgence,  but  particularly  the  former,  are  prolific  sources  of  con- 
tinued palpitation.  We  see  also  those  affected  with  it  who,  addicted 
to  laborious  studies,  give  their  minds  no  rest,  and  grudge  them- 
selves the  necessary  time  for  food,  sleep,  and  exercise.  Women 
who  are  hysterical,  or  whose  uterine  functions  are  disordered, 
suffer  continually,  or  fancy  that  they  suffer  continually,  from  pal- 
pitation. So  do  so-called  nervous  peoj:>le  invariably  complain  of 
the  beating  at  the  heart. 

In  those  whose  blood  is  much  impoverished,  the  palpitations  are 
often  severe  and  constant,  and  their  sensitive  state  of  system  is  apt 
to  be  increased  by  the  fear  of  laboring  under  an  incurable  disease. 
There  is,  indeed,  from  the  strong  resemblance  to  an  organic  affec- 
tion, apparent  cause  for  alarm.  The  heart  strikes  sharply  and 
abruptly  against  the  walls  of  the  chest ;  its  action  is  very  frequent; 
the  breathing  becomes  hurried  on  the  slightest  exertion.  Nay, 
even  the  physical  signs  may  be  those  of  a  structural  lesion.  The 
altered  blood  gives  rise  to  a  blowing  sound  in  the  heart,  which  is 
transmitted  into  the  carotid  and  subclavian  arteries.     The  diffi- 


DISEASES    OF    THE    HEART.  365 

culty  of  diagnosis  is  at  times  great.  The  age ;  the  sex ;  the  anaemic 
look ;  the  presence  of  a  continuous  humming  sound  in  the  veins 
of  the  neck ;  the  strict  synchronism  of  the  murmur  with  the  im- 
pulse ;  its  seat  commonly  at  the  base  of  the  heart, — furnish  a  clue 
to  the  nature  of  the  case.  Still,  we  have  often  to  judge  as  much 
or  more  by  the  absence  of  the  signs  of  cardiac  enlargement,  and 
of  impediment  to  the  flow  of  the  blood,  whether  the  heart  be 
affected  in  its  valvular  apparatus,  or  whether  it  be  simply  func- 
tionally disturbed  and  circulating  watery  blood.  And  even  with 
all  the  assistance  which  the  closest  investigation  can  furnish,  the 
distinction  may  remain  doubtful. 

A  troublesome  kind  of  palpitation  is  that  attended  with  marked 
irregularity  of  the  action  of  the  heart,  displaying  itself  by  the 
beat  being  now  slow,  now  fast,  or  occasionally  intermitting.  Suf- 
ferers from  lithiasis  or  gout,  or  old  persons  whose  stomachs  are 
unable  to  digest  food  properly,  are  particularly  liable  to  it.  This 
form  of  palpitation  is  not  without  danger.  It  is  very  prone  to  be 
associated  with  an  alteration  in  the  structure  of  the  heart,  such  as 
flabbiness  of  the  walls,  which  may  not  be  sufficient  to  yield  any 
distinctive  physical  signs,  but  which  is  nevertheless  sufficient  to  be 
a  source  of  apprehension. 

Some  who  experience  these  fits  of  palpitation  faint  away  during 
them.  But  the  complete,  or  almost  complete,  suspension  of  the 
movements  of  the  heart  which  characterizes  an  attack  of  syncope 
has  no  definite  connection  with  any  form  of  palpitation,  nor,  in- 
deed, with  any  form  of  cardiac  disorder,  organic  or  functional. 

It  has  been  made  a  question  whether,  in  those  who  are  subject 
to  attacks  of  palpitation  or  to  irregular  action  of  the  heart,  the 
organ  may  not  finally  become  enlarged.  There  is  no  reason  why 
this  should  not  take  place,  and  there  is  a  decided  reason  why  it 
should.  If  the  muscles  of  the  arm  be  placed  in  constant  and 
active  motion,  they  increase  in  size.  Why,  then,  may  not  the 
heart,  which  is  composed  of  the  same  kind  of  muscular  fibre,  also 
grow,  if  it  be  often  called  upon  to  act  more  frequently  and  in  a 
different  manner  from  that  to  which  it  is  accustomed?  Hence  we 
ought  to  be  careful  not  to  neglect  any  functional  disturbance  of 
the  heart,  but  aim  at  removing  the  condition  which  keeps  the 
organ  in  a  state  of  irritation,  lest  it  should  suffer  a  mishap  that  no 
exercise  of  skill  can  wholly  repair. 


366  MEDICAL    DIAGNOSE. 

We  sometimes  meet  with  a  singular  form  of  functional  disturb- 
ance of  the  heart  which  leads  to  textural  changes,  and  to  which 
Graves  called  particular  attention.  It  consists  in  a  long-continued 
excitement  of  the  organ,  as  evidenced  by  its  increased  force  and 
rapid  and  irregular  action,  which  is  followed  by  a  swelling  of  the 
thyroid  gland,  pulsation  of  the  arteries  of  the  neck,  and  promi- 
nence of  the  eyeballs.  This  strange  disease,  exophthalmic  goitre, 
is  most  commonly  observed  in  females,  and  connected  with  hys- 
teria, neuralgia,  or  uterine  disturbance ;  and  is  considered  by  many 
as  due  to  an  affection  of  the  cervical  sympathetic  nerve.  All  the 
signs  may  remit  or  may  become  aggravated  from  time  to  time,  and 
especially  during  a  severe  attack  of  palpitation.  The  turgescence 
of  the  thyroid  gland  arises  quite  independently  of  the  usual  ex- 
citing causes  of  bronchocele.  It  is  accompanied  by  a  pulsating 
thrill  similar  to  that  of  an  aneurismal  varix,  and  by  a  distinct 
throb.  At  an  advanced  period  of  the  complaint,  these  signs  sub- 
side, and  the  gland  becomes  more  solid.  Indeed,  the  whole  affec- 
tion may  disappear,  and  the  gland,  the  eyes,  the  beat  of  the  caro- 
tids, the  action  of  the  heart,  may  all  be  brought  back  to  a  normal 
condition.  On  the  other  hand,  hypertrophy  and  dilatation  may 
result  from  the  cardiac  palpitations.  And  the  malady  may  be 
noticed  in  association  with  valvular  disease,  under  circumstances 
which  make  it  a  question  whether  this  has  followed  it  or  is  a  mere 
concomitant.  The  protrusion  of  the  eyeball  is  often  combined 
with  a  symptom  that  Graefe  particularly  observed, — a  want  of 
agreement  between  the  movement  of  the  lid  and  the  raising  or 
depressing  of  the  glance.  Less  constant  symptoms  are  moderate 
elevation  of  temperature,  sensation  of  heat,  and  increased  sweating. 
All  the  manifestations  of  the  disease  are  double-sided ;  and  this, 
with  the  unchanged  state  of  the  pupils,  serves  to  distinguish  it  from 
those  rare  cases  described  by  Eulenberg,*  where  a  thyroid  growth 
pressing  on  the  sympathetic  on  one  side  produces  most  of  the 
symptoms  of  exophthalmic  goitre,  including  the  palpitations. 

In  the  distinction  from  ordinary  goitre,  the  absence  of  eye 
and  heart  symptoms  is  of  most  value.  There  is  also  no  murmur 
heard  over  the  enlarged  thyroid  gland;  whereas  in  Graves'  disease 
a  continuous    murmur  there    is    most    common,  and    is,  indeed, 

*  Ziemssen's  Cyclopaedia. 


DISEASES    OF    THE    HEART.  367 

looked  upon  by  Guttmann  as  of  the  greatest  diagnostic  impor- 
tance, especially  aiding  us  in  those  doubtful  cases  in  which  the 
exophthalmos  is  wanting. 

There  is  another  form  of  functional  disorder  of  the  heart,  so 
peculiar  as  to  demand  a  special  notice.  It  is  the  curious  cardiac 
malady  of  which  we  saw  so  many  examples  in  soldiers  during 
our  late  wTar,  and  to  which  I  have  given  the  name  of  "irritable 
heart,"  and  which  we  also  find  occurring  in  civil  life.  Its  main 
symptoms  are  habitual  frequency  of  the  action  of  the  heart,  con- 
stantly recurring  attacks  of  palpitation,  and  pain  referred  to  the 
lower  portion  of  the  precordial  region.  The  palpitations  come  on 
chiefly  during  exercise,  but  may  also  take  place  when  the  patient 
is  quiet,  and  in  many  cases  happen  most  often,  or  indeed  entirely, 
at  night,  thus  interfering  with  sleep.  Those  who  are  subject  to 
the  disorder  complain  much  of  headache  and  of  dizziness,  and 
especially  of  being  thus  affected  when  suffering  from  palpitation. 
The  pain  is  generally  dull  and  constant,  but  is  often  also  described 
as  shooting,  and  as  taking  place  only  in  paroxysms.  Its  chief  seat 
is  near  the  apex,  and  it  is  combined  commonly  with  excessive 
cutaneous  sensibility.  Often  there  is  pain  nowhere  else  in  the 
body ;  but  in  some  instances  the  cardiac  distress  is  associated  with 
pain  in  the  back,  which  itself  is  not  unusually  connected  with  the 
excretion  of  oxalate  of  lime  by  the  kidneys. 

The  action  of  the  heart  is  very  rapid,  and  in  many  instances  its 
rhythm  is  irregular.  The  impulse  is  slightly  extended,  but  not 
forcible,  like  that  of  hypertrophy :  it  is  rather  abrupt  and  jerky. 
As  a  rule,  to  which  I  have  met  with  but  few  exceptions,  the  sounds 
of  the  heart  are  modified  as  follows  :  the  first  sound  is  short,  some- 
times sharp,  resembling  the  second  sound;  at  other  times  it  is  ex- 
tremely deficient  and  hardly  recognizable ;  the  distinctness  of  the 
second  sound  is  much  heightened.  We  either  hear  no  murmurs 
in  the  heart  or  in  the  neck,  or  they  are  inconstant.  The  area  of 
percussion  dulness  does  not  appear  to  be  augmented.  The  pulse 
is  almost  always  easily  compressible;  it  may  or  may  not  share  the 
character  of  the  impulse.  It  is  usually  very  much  influenced  by 
position,  falling  rapidly  twenty  beats  or  more  when  the  erect 
posture  is  exchanged  for  the  recumbent.  The  increased  frequency 
of  beat  is  not  connected  with  increased  frequency  of  respiration, 
for  often  with  a  pulse  of  one  hundred  the  respirations  scarcely 


368  MEDICAL    DIAGNOSIS. 

exceed  twenty  in  the  minute.  The  disorder  is  very  obstinate,  and 
improvement  comes  but  slowly.  Keeping  the  heart  quiet  by  oc- 
casional doses  of  digitalis  or  of  veratrum  viride,  or  by  atropia, 
and  improving  its  tone  as  much  as  possible  by  tonics,  is  the  treat- 
ment which  I  found  to  be  the  most  successful. 

The  cause  of  the  morbid  cardiac  impressibility  is  difficult  to  as- 
certain. It  seems,  in  many  instances,  to  have  followed  fatiguing 
marches;  in  some  it  occurred  after  fevers  or  diarrhoea;  it  was  not 
connected  with  scurvy,  or  with  the  abuse  of  tobacco.  That  it  was 
not  due  to  anaemia,  was  proved  by  the  general  aspect  of  the  men, 
which  was  often  that  of  ruddy  health.  For  a  fuller  consideration 
of  the  subject  I  refer  to  observations  elsewhere  detailed.* 

These,  then,  are  the  principal  varieties  of  functional  disorder 
of  the  heart.  It  is  hardly  necessary  again  to  state  that  the  phys- 
ical signs  present  the  most  certain,  if  not  the  only,  means  of  dis- 
tinguishing the  functional  from  the  structural  affection.  They 
show  us  that  neither  the  size  of  the  organ,  nor  its  sounds,  with 
the  exceptions  above  mentioned,  are  materially  different  from 
what  they  are  in  health. 

The  irritable  heart  just  described,  as  indeed  other  forms  of 
functional  heart  disorder,  may  pass  into  organic  cardiac  disease  by 
the  constant  overaction  of  the  heart.  And  overaction  or  strain  may 
also,  as  I  have  proved  in  the  publications  just  referred  to,  lead  to 
valvular  affection,  sometimes  by  preceding  hypertrophy,  at  other 
times  by  a  slow  process  of  inflammation  or  disorganization  engen- 
dered at  or  near  the  seat  of  the  valve.  Of  this  I  published  several 
instances  in  the  "  Memoirs  of  the  Sanitary  Commission."  Others 
have  been  brought  forward  by  Dr.  Allbuttf  which  happened 
among  persons  engaged  in  avocations  requiring  sustained  and  oft- 
repeated  muscular  effort, — such  as  lifters,  smiths,  sawyers.  And 
in  his  elaborate  monograph  SeitzJ  has  detailed  several  fatal  cases 
in  which  the  symptoms  of  a  fatigued  heart,  due  to  strain,  were 
followed  by  extensive  dilatation  without  valvular  disease. 

*  Medical  Memoirs  of  the  U.  S.  Sanitary  Commission,  1867 ;  American 
Journal  of  the  Medical  Sciences,  January,  1871 ;  and  the  Third  Toner  Lec- 
ture, 1874,  "On  Strain  and  Overaction  of  the  Heart." 

f  St.  George's  Hospital  Reports,  1872. 

J  Die  Ueberanstrengung  des  Herzens,  187-3. 


DISEASES    OF    THE    HEART. 


369 


ORGANIC  DISEASES   OF  THE   HEART. 

Organic  diseases  of  the  heart  may  be  classified  as  follows : 
Organic  Diseases  oe  the  Heart. 

Diseases  affecting  the  walls  of  the  heart,   r  Hypertrophy, 
and  mostly  changing  the   size  of  the  -J   Dilatation, 
cavities.  I  Atrophy. 

Patty  degeneration. 
Malformations. 
Eupture  of  the  heart. 
Injuries  and  wounds. 
Aneurism  of  the  heart. 
New  growths  and  parasites, 
f  of  membranes.  /  Endocarditis. 

Inflammations J   of  muscular        I  Pericarditis. 

[      structure.        i   Myocarditis  (Carditis). 

Diseases  of  the  valvular  apparatus j  Valvular  diseases. 

Chronic  pericarditis. 


Diseases  affecting  chiefly  the  walls  alone. 


Diseases  affecting  the  pericardium. 


Congenital  diseases. 


Hydropericardium. 

Hsemopericardium. 

Pneumo-hydropericardium. 

New  formations  on  pericardium. 

Abnormal  positions. 

Closure  of  openings  of  right 
heart. 

Opening  between  the  ventricles. 

Narrowing  and  closure  of  pul- 
monary artery,  etc. 


These  are  all  the  organic  diseases  of  the  heart,  save  the  rarest. 
But  let  us  study  the  cardiac  maladies  rather  according  to  their 
symptoms  and  signs  than  according  to  their  anatomical  classi- 
fication.    And  first  let  us  investigate  a  group  of  acute  affections. 


Acute  Diseases  presenting  Pain  in  the  Cardiac  Region;  the 
Symptoms  of  a  Disturbed  Circulation ;  and  a  Change  in  the 
Sounds  of  the  Heart,  or  their  Eeplacement  by  Murmurs, 

All  the  acute  affections  of  the  heart  come  under  this  head.  In 
all,  the  sounds  are  either  changed  in  their  character  or  are  replaced 
by  murmurs.     This  is  certainly  true  of  the  only  acute  diseases  of 

24 


370  MEDICAL    DIAGNOSIS. 

which  we  have  anything  like  an  accurate  knowledge, — endocar- 
ditis and  pericarditis.  All  the  acute  disorders  give  rise  further 
to  more  or  less  pain,  and  to  anxiety  of  expression ;  in  all  there 
is  fever ;  all  are  prone  to  occur  in  connection  with  other  morbid 
conditions,  and  especially  with  a  contaminated  state  of  the  blood. 
In  all,  moreover,  the  symptoms  of  a  disturbed  circulation  are  met 
with  :  palpitation,  irregular  action  of  the  heart,  deranged  flow  of 
blood  through  the  capillaries  of  different  organs,  and  a  tendency 
to  dropsical  accumulations.  That  these  symptoms  are  not  so  clearly 
denned  as  in  some  of  the  chronic  cardiac  maladies,  is  owing  to  the 
shorter  time  the  complaint  lasts. 

Acute  Endocarditis. — Acute  inflammation  of  the  lining 
membrane  of  the  heart  arises  from  exposure  to  cold,  or  without 
any  cause  being  discoverable.  It  sometimes  results  from  violent 
efforts,  or  from  blows  or  other  injuries  to  the  chest.  It  is  often 
connected  with  a  vitiated  condition  of  the  blood,  as  in  pyaemia, 
in  puerperal  fever,  or  in  Bright's  disease.  But  its  more  frequent 
association  is  with  acute  articular  rheumatism. 

As  the  anatomical  characters  illustrate  the  physical  signs  and 
many  of  the  symptoms  of  the  disease,  they  may  be  here  briefly 
described.  The  membrane  itself  loses  its  transparency  and  smooth- 
ness, and  is  injected.  On  its  free  surface  lymph  exudes,  and  is 
moulded  into  patches  of  various  size,  which  may  be  torn  off  by 
the  blood  and  washed  into  the  circulation;  and  so  may  the  coagula 
which  form,  in  severe  cases,  in  the  chambers  of  the  heart.  The 
inflammation  stops  short  at  the  muscular  structure.  Yet  it  may 
implicate  this,  and  result  in  softening  the  walls  of  the  heart,  or  in 
developing  purulent  cysts  in  them.  It  is  not  uncommon  to  find 
the  pericardium  involved,  and  then  the  serous  lining  of  the  heart 
and  its  serous  covering  are  both  the  seat  of  exudation.  But  the 
inflammation  inside  is  not  usually  as  extensive  as  the  inflamma- 
tion without.  Indeed,  the  chief  source  of  danger  in  endocarditis 
is  this  very  tendency  to  limit  itself.  It  is  confined  to,  or  is  most 
strikingly  developed  at,  a  part  which  bears  least  of  all  any  impair- 
ment,— at  the  valves, — and  often  leaves  behind  it  some  permanent 
disorganization  of  their  delicate  structure.  But  it  does  not  gen- 
erally affect  the  entire  valvular  apparatus  :  that  of  the  left  side  is 
usually  alone  the  seat  of  disease. 

What  morbid   anatomy  thus  teaches,  explains  the  occurrence 


DISEASES    OP    THE    HEART.  371 

and  situation  of  the  principal  sign  by  which  endocarditis  is  recog- 
nized. The  roughness  of  the  surface  over  which  the  blood  flows, 
or  the  lymph  deposited  on  or  in  the  neighborhood  of  the  valves, 
interfering  with  their  function,  occasions  a  distinct  murmur,  which 
is  mostly  confined  to  the  mitral  and  aortic  openings. 

Besides  this  blowing  sound,  there  are  other  signs  worthy  of 
note.  It  is  true,  they  do  not  form  so  leading  a  feature  of  the 
disease;  still,  they  aid  in  its  correct  appreciation.  The  excited 
heart  beats  with  augmented  force,  and  sometimes  with  great  ir- 
regularity, as  the  not  unusual  doubling  of  the  second  sound  at 
the  base  proves.  The  size  of  the  organ  is  not  notably  increased, 
except  in  those  cases  in  which  its  cavities  are  choked  with  blood 
or  fibrin-clots.  The  pulse  corresponds  to  the  action  of  the  heart ; 
yet  not  so  closely  as  might  be  expected.  It  is,  for  the  most  part, 
frequent  and  strong,  and  rather  forcible  at  first ;  sometimes  it  is 
small  and  frequent.  It  becomes  irregular,  one  beat  being  strong, 
the  next  weak,  if  the  circulation  through  the  heart  be  seriously 
obstructed.  But  it  may  be  feeble  while  the  heart  is  thumping 
with  violence  against  the  walls  of  the  chest.  Occasionally  at  the 
onset  of  the  attack  it  has  been  observed  to  be  slower  than  natural. 

The  general  symptoms  are  not  always  uniform.  There  is 
usually  a  sense  of  uneasiness  around  the  heart,  with  decided 
fever,  a  short  cough,  difficulty  of  breathing,  and  an  extreme 
anxiety  depicted  on  the  countenance.  To  these  are  not  uncom- 
monly added  a  turgescence  of  the  face,  headache,  some  wandering 
of  the  mind,  a  yellowish  hue  of  the  skin,  gastric  irritability, 
diarrhoea,  and  rigors,  followed  by  sensations  of  heat.  Excessive 
pain  in  the  heart  is  rare,  and  is  not  likely  to  happen  unless  the 
pericardium  or  the  muscular  walls  be  implicated. 

Now,  where  these  symptoms  are  present ;  where  they  manifest 
themselves  in  one  whose  system  is  in  a  state  in  which  endocarditis 
is  apt  to  take  place;  and  where  they  are  accompanied  by  a  blow- 
ing sound  recently  and  rather  suddenly  developed, — -we  are  cer- 
tain that  inflammation  is  working  its  changes  in  the  lining  mem- 
brane of  the  heart.  Yet  some  circumspection  is  requisite  before 
arriving  at  this  conclusion,  and  before  the  patient  is  subjected  to 
energetic  treatment  with  the  view  of  saving  him  from  the  sup- 
posed damage  which  his  heart  is  about  to  undergo.  A  murmur 
may  be  attended  with  febrile  signs  and  not  be  dependent  upon 


372  MEDICAL    DIAGNOSIS. 

acute  endocarditis.  The  sound  may  be  of  organic  origin ;  or  it 
may  be  engendered  in  the  course  of  an  idiopathic  fever,  and  the 
lining  membrane  of  the  heart  be  unaltered. 

In  the  first  instance  the  murmur  is  old,  and  results  from  some 
chronic  injury  to  the  valve,  the  attending  fever  being  an  accidental 
complication.  Here  is  undoubtedly  a  difficult  case  for  diagnosis. 
We  see  the  patient  for  the  first  time:  he  has  fever;  his  heart  is 
acting  strongly;  a  distinct  blowing  sound  is  perceived  over  it. 
How  are  we  to  tell  that  his  complaint  is  not  acute  endocarditis? 
We  have  no  absolute  means  of  deciding  that  it  is  not.  Yet  by 
careful  inquiry  we  can  usually  come  to  a  knowledge  of  the  truth. 
If  the  patient  do  not  recollect  to  have  suffered  previously  from 
dyspnoea,  palpitation,  or  other  signs  of  an  affection  of  the  heart; 
if  the  cardiac  excitement  and  irritation  be  well  defined ;  if  the 
face  denote  distress;  if  the  accompanying  symptoms  indicate  a 
state  which  is  prone  to  be  complicated  with  endocardial  inflam- 
mation,— it  is  this  disease  under  which  he  is  laboring.  I  may 
add  another  and  very  important  element  of  distinction  deduced 
from  the  study  of  the  blowing  sound,  to  wit,  that  the  murmur  of 
endocarditis  is  not  so  rough,  is  not  often  heard  during  the  dis- 
tention of  the  heart,  and  may  be  changeable  in  its  seat,  which  an 
old-standing  murmur  never  is.  Besides,  it  is  not  associated  with 
those  signs  of  enlargement  which  are  invariably  found  when  the 
valves  have  been  for  any  length  of  time  affected,  unless  the  acute 
inflammation  occur  in  a  heart  the  valves  of  which  have  been 
previously  spoiled.  Under  such  circumstances,  we  can  only  con- 
jecture what  is  going  on  within  the  organ  by  its  increased  excite- 
ment, and,  if  I  may  take  my  own  experience  as  the  general  rule, 
by  the  character  of  the  blowing  sound  being  altered.  It  is  ren- 
dered often  less  distinct,  nay,  it  is  even  entirely  muffled,  by  the 
products  of  the  recent  inflammation. 

But  how  are  we  to  distinguish  between  the  soft  murmur  arising 
in  the  course  of  fevers,  and  that  resulting  from  effused  lymph  ? 
It,  too,  is  not  rough.  It,  too,  happens  with  the  impulse.  It,  too, 
is  preceded,  as  some  cases  of  endocarditis  are,  by  a  lengthening  of 
the  first  sound.  Here  is  assuredly  a  strong  resemblance;  yet  by 
no  means  an  identity.  The  blowing  sound  in  fevers  does  not 
exist  until  the  blood  is  profoundly  altered.  In  endocarditis  it 
takes  place  almost  as  soon  as  the  disease  begins, — certainly  as  soon 


DISEASES    OF    THE    HEART.  373 

as  we  are  able  to  recognize  positively  its  beginning.  The  heart 
in  fevers  may  be  softened,  but  it  is  not  so  directly  disturbed  in  its 
action.  We  do  not  find  those  symptoms,  local  as  well  as  general, 
which  show  that  the  circulation  is  obstructed.  The  blowing  sound 
is  rarely  at  the  apex,  but  more  over  the  body  of  the  heart.  To  this 
some  weight  mav  be  attached,  since  the  murmur  of  endocarditis  is 
very  apt  to  be  heard  at  the  apex.  But  to  no  fact  ought  as  much 
weight  to  be  attached  as  to  the  one  first  mentioned,  that  the  mur- 
mur takes  place  early,  and  not  late  in  the  disease. 

Throughout  this  description  of  endocarditis,  only  simple,  un- 
complicated cases  have  been  kept  in  view ;  yet  it  is  not  often  that 
the  malady  is  seen  in  so  pure  a  type.  It  is  more  generally  accom- 
panied by  the  friction  sounds  and  other  signs  of  acute  pericarditis, 
and  by  the  swollen  joints,  the  painful  movements,  the  acid  per- 
spirations of  acute  rheumatism. 

Xor  is  what  has  been  said  of  endocarditis  manifesting  itself  by  a 
murmur  invariable.  If  the  question  be  asked,  "  Can  endocarditis 
occur  without  a  blowing  sound  ?"  it  must  be  answered  in  the 
affirmative.  When  the  seat  of  the  inflammation  is  not  near  the 
valves,  no  murmur  is  generated.  There  may  be  also  none  if  no 
vegetations  exist  on  the  valves,  and  perhaps  in  states  of  the  exu- 
dation with  which  we  are  at  present  unacquainted.  We  cannot, 
under  such  circumstances,  detect  an  attack  of  endocarditis.  Yet 
it  may  be  even  then  strongly  suspected  to  be  present  if  great 
excitement  and  irritation  of  the  heart  manifest  themselves  in  a 
person  who  is  laboring  under  a  disease  which  predisposes  to  endo- 
cardial inflammation,  such  as  rheumatism.  Cases  of  this  nature 
are,  however,  exceptional.  They  do  not  happen  sufficiently  often 
to  invalidate  the  value  of  the  statement  that  the  development  of  a 
murmur  is  the  sign  indicative  of  endocarditis.  Still,  they  happen 
sufficiently  often  to  impress  upon  us  that  our  knowledge  of  endo- 
carditis is  not  complete. 

The  clinical  study  of  endocarditis  is,  in  truth,  a  comparatively 
recent  study.  There  are  some  points  about  it  which  are  as  yet 
unknown,  and  others  which  have  only  recently  been  or  are  still 
being  cleared  up.  To  this  class  belong  those  interesting  researches 
on  the  formation  of  clots  of  fibrin  in  the  heart,  and  on  the  effects 
produced  when  they  or  the  vegetations  which  stud  the  valves  are 
washed  into  the  circulation.     The  formation  of  clots  in  the  cardiac 


374  MEDICAL    DIAGNOSIS. 

cavities,  if  at  all  extensive,  announces  itself  by  a  sudden  appearance 
or  a  sudden  augmentation  of  the  symptoms  of  obstructed  circula- 
tion :  the  skin  is  cold,  and  the  surface  may  be  bluish ;  there  is  a 
struggle  for  breath,  the  pulse  is  frequent  and  feeble,  the  action  of 
the  heart  becomes  exceedingly  irregular,  its  sounds  are  indistinct, 
or  a  more  or  less  distinct  murmur  is  heard,  and  the  extent  of 
the  precordial  percussion  dulness  is  somewhat  increased.  Great 
anxiety  of  countenance,  nausea,  vomiting,  excitement  of  the  ner- 
vous system  and  delirium,  turgid  veins  in  the  neck,  and  fits  of 
fainting,  are  also  among  the  manifestations  of  the  clogged  flow  of 
blood  through  the  heart.  Yet  these  phenomena  are  not  absolutely 
distinctive;  for  so  great  an  observer  as  Walshe  records  that  the 
effects  of  a  rupture  of  a  sigmoid  valve  or  of  a  tendinous  cord, 
during  the  acute  endocardial  disease,  will  give  rise  to  symptoms 
exactly  similar  to  the  obstruction  of  the  circulation  resulting  from 
polypoid  concretions  in  the  heart. 

Xow,  portions  of  the  clots,  or  of  the  vegetations  on  the  valves, 
are  sometimes  washed  into  the  current,  and  the  embolism  occasions 
symptoms  which,  before  we  were  aware  of  the  damages  to  which 
the  detached  masses  may  give  rise,  appeared  inexplicable.  At 
present — thanks  to  Virchow,  Kirkes,  and  Paget — when  we  see  the 
circulation  speedily  diminished  or  arrested  in  a  limb,  and  the 
limb  becoming  painful,  swelling,  or  beginning  to  mortify;  when 
we  find  that  the  flow  of  the  blood  through  the  brain  has  become 
suddenly  disturbed,  and  the  muscles  of  one  side  drop  paralyzed ; 
when  the  difficult  breathing  becomes  rapidly  still  more  difficult, 
while  there  are  no  signs  of  a  superadded  affection  of  the  lung; 
nay,  while  the  power  fully  to  expand  the  lungs  remains  unim- 
paired, or  while  an  effusion  of  fluid  into  the  air-vesicles  follows 
the  dyspncea, — we  know  what  lias  happened :  we  know  that  a 
broken-off  piece  of  fibrin  has  been  driven  into  the  artery  of 
the  limb,  or  into  the  brain,  or  into  the  branches  of  the  pulmo- 
nary artery,  and,  being  too  large  to  go  any  farther,  has  stuck  fast, 
and  has  given  rise  to  all  of  these  sudden  and  sad  consequences. 
Sad  indeed  they  are;  for,  even  if  the  plugs  do  not  lead  to  an 
immediately  fatal  result,  they  are  apt  to  lay  the  groundwork  for 
structural  alterations  in  any  organ  or  tissue  in  which  they  become 
impacted. 

But  let  it  not  be  understood  that  the  detachment  of  vegetations 


DISEASES    OF    THE    HEART.  375 

from  the  valves,  or  of  fragments  of  clot  formed  in  the  cavities  of 
the  heart,  happens  only  in  endocarditis.  Pieces  have  been  found 
which  were  separated  from  valves  that  were  in  a  state  of  chronic 
induration  or  so-called  ossification.  And  the  blood  in  the  heart 
may  clot  from  any  interference  with  the  current,  from  heart  palsy, 
or  from  changes  in  the  vital  fluid  wholly  unconnected  with  in- 
flammation. But  when  it  coagulates,  from  whatever  cause,  the 
symptoms  are  the  same  as  those  just  described.  A  murmur,  too, 
is  not  uncommonly  produced,  which  is  not  distinguishable  from 
that  due  to  endocardial  inflammation,  but  which  is  not  of  long 
duration,  since  death  generally  follows  the  impediment  in  the 
heart  in  a  feAV  days  at  farthest. 

Inflammation  of  the  aorta  may  occasion  many  of  the  symptoms 
of  acute  endocarditis ;  at  all  events,  it  may  do  so  when  the  upper 
part  of  the  aorta  is  implicated.  But  it  cannot  be  said  that  it  is  a 
condition  which  with  certainty  may  be  discriminated.  The  most 
significant  signs  are  hurried  respiration,  a  sharp,  rapid  pulse,  tu- 
multuous action  of  the  heart,  pain  in  the  precordial  region,  often 
severely  increased  by  movements,  and  also  felt  along  the  course 
of  the  spine,  and  a  loud  systolic  blowing  sound.  When  the 
abdominal  aorta  is  affected,  there  is  a  strong  local  pulsation,  and 
a  marked  murmur  will  be  heard  with  greatest  distinctness  at  or 
near  the  seat  of  the  inflammation.  In  some  cases  of  aortitis, 
Bright*  noticed  an  extremely  high  degree  of  morbid  sensibility 
over  all  parts  of  the  body,  which  caused  the  patient  to  scream 
with  pain  when  his  wrists  were  merely  touched.  The  disorder  is 
most  apt  to  happen  in  cachectic  persons ;  and  it  has  been  repeat- 
edly observed  in  those  attacked  with  erysipelas,  or  after  opera- 
tions and  injuries.f 

There  is  a  form  of  endocarditis  which  may  be,  in  conclusion, 
here  briefly  mentioned, — ulcerative  endocarditis.  It  is  not  common 
in  this  country,  although  I  have  seen  instances  of  the  malady. 
It  occurs  mostly  in  connection  with  blood-poisoning,  and  the 
symptoms  of  this  or  of  pysemia  or  a  low  septic  fever  are  appar- 
ently the  prominent  features  of  the  case.  The  ulceration  perfo- 
rates the  valves,  and  may  extend  into  the  muscular  structure  of  the 


*  Guy's  Hospital  .Reports,  vol.  i. 

f  Chevers,  ib.,  vol.  vi.,  and  2d  Series,  vol.  i. 


376  MEDICAL    DIAGNOSIS. 

heart ;  pneumonia  or  pleurisy,  embolic  formations,  and  metastatic 
abscesses  in  various  parts  of  the  body  are  among  the  common 
attendants.  The  perilous  affection  shows  an  endocarditis  with  the 
ordinary  physical  signs  developing  amidst  the  symptoms  of  pro- 
found blood-poisoning  and  prostration,  although  these  physical 
signs  may  be  masked  by  a  pericardial  complication.  Marked  and 
recurring  chills,  like  those  of  malarial  fever,  but  coming  on  ir- 
regularly ;  a  temperature  of  105°  to  107°  ;  an  extremely  rapid 
pulse  becoming  suddenly  much  slower,  though  very  irregular; 
profuse  sweats;  vertigo;  delirium  followed  by  stupor;  dry  tongue; 
vomiting  and  diarrhoea;  jaundice;  tenderness  over  liver  and 
spleen ;  and  scanty,  albuminous  urine, — are  among  the  prominent 
features  of  the  malady.  As  regards  the  thoracic  symptoms,  there 
may  be  oppression,  dyspnoea,  and  pain,  as  ordinarily  in  endocar- 
ditis, yet  these  symptoms  may  be  wholly  wanting.  In  some  in- 
stances a  peculiar  diffused  rose  rash,  here  and  there  mixed  with 
papules  and  spots  of  ecchymosis,  is  noticed.  By  some,  ulcerative 
endocarditis  is  looked  upon  as  diphtheritic;  certainly  when  it 
has  happened  during  puerperal  fever  diphtheritic  exudations  have 
been  found  on  the  mucous  membrane  of  the  vagina  and  uterus. 
Death  is  the  common  ending, — either  from  gradual  exhaustion,  or 
suddenly  by  the  tearing  away  of  the  injured  valves. 

Acute  Pericarditis. — Acute  inflammation  of  the  serous 
membrane  of  the  exterior  of  the  heart  is  very  similar  to  that 
of  its  interior.  It  is  developed  under  the  same  circumstances. 
It  exhibits  the  same  frequent  association  with  rheumatism ;  it 
presents  the  same  symptoms.  Nature  has  not,  indeed,  drawn  a 
very  strict  line  of  demarcation  between  the  two  diseases.  When 
one  exists,  the  other  is  very  apt  to  attend  it.  Yet  we  do  meet 
with  endocarditis  without  pericarditis,  and  more  often  still  with 
pericarditis  without  endocarditis. 

The  anatomical  effects  of  inflammation  of  the  pericardium  are 
like  those  of  acute  endocarditis,  and  resemble  still  more  closely 
those  which  inflammation  of  the  adjoining  serous  membrane — the 
pleura — occasions.  The  pericardium  becomes  injected  and  dry; 
plastic  lymph  accumulates  on  its  surfaces,  and  especially  on  the 
surface  which  fits  tightly  around  the  heart.  The  extent  and 
appearance  of  the  deposited  lymph  are  very  various.  It  may  be 
limited  to  part  of  the  covering  of  one  ventricle,  or  be  distributed 


DISEASES    OF    THE    HEART. 


377 


in  layers  all  over  the  inner  face  of  the  membrane.  This  stage  of 
the  disease  corresponds  to  the  dry  stage  of  acute  pleurisy.  It  may 
have  the  same  termination  by  the  two  roughened  surfaces  adhering. 
But  it  is  often  followed  by  a  stage  similar  to  that  of  pleural  effu- 
sion. The  bag  in  which  the  heart  lies  is  filled  with  fluid;  some- 
times with  serum  in  which  flocculi  of  lymph  float ;  at  times  with 
a  thicker,  more  highly  albuminous  liquid;  less  frequently  with  a 
watery  blood,  or  with  pus.     The  effusion  may  remain  stationary 

Fig.  32. 


Illustration  nf  the  position  of  the  heart  in  pericarditis,  and  of  the 
distention  of  the  pericardium  'with  fluid.  The  heart-sounds  are  in- 
distinct, except  above  the  effusion ;  the  impulse  is  feeble.  The 
extent  and  shape  of  the  percussion  dulness  may  be  judged  of  by  the 
appearance  of  the  distended  sac. 


or  be  absorbed,  and  the  rugged  portions  of  the  membrane  be 
placed  again  in  apposition. 

Now,  from  a  knowledge  of  these  anatomical  changes,  the  phys- 
ical signs  may  be  foretold.  It  is  obvious  that  there  must  be  at 
first  a  friction  sound ;  that  then  the  fluid  which  distends  the  peri- 
cardium will  increase  the  area  of  percussion  dulness  over  the  heart, 
and  prevent  the  sounds  and  the  impulse  from  being  distinctly 
perceived.     But  the  friction  sound  is  not  always  the  same  in  ex- 


5<8  MEDICAL    DIAGNOSIS. 

tent  or  in  character,  because  the  deposited  lymph  is  not  always  the 
same  in  extent  or  in  character.  The  sound  is  like  the  crumpling 
of  parchment,  or  the  creaking  of  new  leather,  or  it  is  grazing,  or 
like  a  scries  of  irregular  clicks.  It  is  a  single  or  it  is  a  double 
sound,  and  is  prone  to  mask  the  natural  sounds  of  the  heart. 
But  these  are  all  points  which  have  been  already  described :  we 
shall  merely  add  that  when  the  friction  develops  itself  under  our 
observation,  and  with  signs  of  excitement  of  the  heart,  it  is  as  dis- 
tinctive of  inflammation  of  the  pericardium  as  a  recent  blowing 
sound  is,  under  the  same  circumstances,  distinctive  of  inflamma- 
tion of  the  endocardium.  When  the  pericardial  effusion  takes 
place,  it  ceases;  but  only  gradually,  and  not  always  completely; 
and  in  any  case  it  is  not  uncommon  for  the  ear  still  to  recognize 
the  murmur  at  the  base  of  the  heart  and  around  the  origin  of  the 
great  vessels. 

The  percussion  dulness  due  to  the  effusion  is  generally  consid- 
erable ;  and  its  contour  is  characteristic.  As  the  fluid  gravitates 
to  the  lower  portion  of  the  sac,  this  distends,  of  necessity,  more 
than  the  part  where  the  pericardium  adheres  to  the  vessels.  The 
consequence  is  that  the  dulness,  when  the  patient  is  in  the  erect 
posture,  is  pyramidal ;  when  he  lies  on  his  back,  or  changes  from 
side  to  side,  the  outline  of  the  flat  sound  is  somewhat  altered. 
R,otch,*  in  an  elaborate  inquiry  into  the  matter,  points  to  the 
dulness  in  the  fifth  intercostal  space  to  the  right  of  the  sternum 
as  occurring  even  in  small  effusions,  and  as  an  available  diag- 
nostic sign  ;  and  Roberts,f  in  his  excellent  monograph,  speaks 
of  the  valuable  aid  afforded  by  it  to  surgeons  about  to  tap  the 
pericardium. 

In  cases  of  considerable  effusion,  the  intercostal  spaces  of  the 
cardiac  region  widen,  the  eye  recognizes  a  distinct  bulging,  and 
the  dulness  on  percussion  reaches  to  the  second,  or  even  to  the 
first,  rib.  Within  the  space  of  dulness  is  sometimes  seen  an  irreg- 
ular, wavy  motion  ;  and  what  the  eye  detects,  the  hand  feels.  Yet 
no  movements,  or  only  slight  movements,  may  be  perceptible  in 
the  preecordia.  The  heart,  with  its  point  pushed  upward  by  the 
accumulating   liquid,  has  to  struggle  to  reach  the  walls  of  the 


*  Boston  Med.  and  Surg.  Journ.,  1878,  vol.  xcix. 
f  Paracentesis  of  the  Pericardium,  Phila.,  1880. 


DISEASES    OF    THE    HEART.  379 

chest.  Its  contractions  are  irregular;  its  impulse  is  feeble,  or  all 
appreciable  impulse  has  ceased.  The  sounds  heard  through  the 
mass  of  fluid  seem  distant  and  muffled.  Yet  the  second  sound 
over  the  upper  part  of  the  sternum  and  at  the  base  of  the  heart 
retains  its  sharpness. 

During  the  stage  of  absorption  the  apex  returns  to  its  normal 
position;  the  dulness  gradually  disappears ;  the  sounds  and  the 
impulse  regain  more  of  their  normal  character ;  the  friction  mur- 
mur reappears,  and  then  ceases,  leaving  frequently  the  two  sur- 
faces of  the  pericardium  glued  together, — a  condition  which  is  not 
harmless,  since  it  not  unusually  leads  to  dilated  hypertrophy,  or 
to  dilatation. 

We  cannot  foretell  how  long  it  will  take  for  the  disease  to  run 
through  its  different  stages.  Death  may  occur  in  less  than  thirty 
hours,  the  heart  being  paralyzed  by  an  enormous  effusion ;  on  the 
other  hand,  the  acute  attack  may  last  for  as  many  days,  and  then 
leave  serious  traces.  But  whatever  stage  the  malady  be  in,  it  can 
be  recognized  only  by  the  physical  signs  just  detailed  :  by  the 
friction,  the  peculiar  percussion  dulness,  the  enfeebled  impulse 
and  heart-sounds. 

There  are  no  general  symptoms  that  prove  a  pericarditis  to 
exist.  There  are  symptoms  by  which  we  may  infer  that  peri- 
carditis is  present;  but  there  are  none  which  absolutely  belong  to 
it  and  would  prevent  it  from  being  overlooked.  The  symptoms 
usually  met  with  are  those  of  inflammation  of  the  endocardium, 
but  with  more  decided  local  evidence  of  disorder.  "We  find  the 
anxious  expression ;  the  fever ;  the  oedema ;  the  same  uncertain 
or  irregular  pulse.  But  there  is  more  pain  over  the  heart, — acute, 
severe  pain,  shooting  to  the  left  shoulder,  augmented  by  move- 
ment, increased  by  pressure ;  there  is  more  dyspnoea,  because  the 
distended  sac  presses  on  the  lung;  and  there  is  sometimes  diffi- 
culty in  swallowing.  Yet  every  one  of  these  symptoms  may  be 
absent.  The  pulse  may  be  regular ;  the  breathing  not  perceptibly 
accelerated,  or  laborious ;  and  even  the  symptom  regarded  as 
the  most  important  of  all — the  pain — may  be  wanting  from  the 
beginning  to  the  end  of  the  disease. 

When  the  action  of  the  heart  grows  weaker  and  weaker,  the 
circulation  becomes  more  irregular.  The  beat  of  the  artery  at 
the  wrist  is  feeble,  and    intermits ;   the  veins  of  the   neck  are 


380  MEDICAL    DIAGNOSIS. 

prominent;  the  skin  is  cold  and  pale;  the  extremities  are  cedema- 
tous.  These  are  always  symptoms  of  grave  import :  they  tell  of 
the  failing  power  of  the  heart,  and  call  for  agents  which  will 
sustain  it. 

If  next  we  inquire  with  what  complaints  acute  pericarditis  is 
likely  to  be  confounded,  inflammation  of  the  endocardium  and  of 
the  pleura  occur  at  once  to  the  mind.  To  contrast  the  signs  of 
the  first  two  maladies,  for  the  slight  difference  in  their  symptoms 
has  already  been  alluded  to  : 

Endocarditis.  Pericarditis. 

Blowing  sound  ;  excited  action  of  the  Friction  sound  ;  excited  action  of  the 

heart.  heart. 

Slight,  if  any,  increase  of  percussion  In  stage  of  effusion,  marked  and  ex- 

dulness.  tended  percussion  dulness. 

Impulse  strong.  Impulse  wavy  and  feeble. 

Sounds  normal  or  more  distinct,  ex-  Sounds  feeble  and  muffled,  except  at 

cept  at  site  where  murmur  is  heard.  base  ;  no  blowing  sounds. 

Such  is  the  distinction  of  pure  cases  of  each  disease.  Still, 
as  already  stated,  the  affections  are  often  combined.  It  is  not 
uncommon  to  hear  with  the  friction  sound  a  distinct  endocardial 
murmur.  But  there  is  sometimes  a  difficulty  of  another  kind  in 
the  way  of  a  precise  diagnosis.  The  murmur  produced  on  the 
outside  of  the  heart  may  simulate  so  closely  the  murmur  produced 
in  its  interior  that  it  is  almost  impossible  to  discriminate  between 
them.  The  former  may  completely  possess  the  blowing  characters 
of  the  latter.  Mostly,  however,  it  is  rougher ;  more  prone  to  be 
double ;  and  each  division  is  like  the  other,  equally  rough,  equally 
superficial-sounding,  equally  lacking  in  strict  correspondence  to 
the  systole  or  to  the  diastole.  And,  above  all,  the  sound  alters 
at  times  both  in  situation  and  in  character  with  amazing  rapidity. 
Perceived  now  as  an  ordinary  bellows  murmur  on  the  left  side,  it 
is  after  the  lapse  of  some  hours  heard  as  a  rough  rasping  sound 
on  the  right.  These  changes  have  a  high  degree  of  value.  But 
they  are  not  of  constant  occurrence;  and  to  say  that  it  is  some- 
times impossible  to  tell  a  pericardial  from  an  endocardial  sound 
is  to  say  no  more  than  is  borne  out  by  every-day  experience. 
Fortunately,  in  point  of  treatment,  an  error,  should  it  be  com- 
mitted, is  not  fatal  to  the  patient's  safety;  for,  at  all  events  before 


DISEASES    OF    THE    HEAET.  381 

the  stage  of  effusion  in  pericarditis,  the  two  diseases  require  much 
the  same  means  for  their  relief;  and  endocarditis  is  not  likely  to 
be  mistaken  for  pericarditis  in  its  stage  of  effusion. 

Pleurisy  gives  rise  to  some  of  the  same  symptoms  and  signs  as 
pericarditis.  It  develops  a  friction  sound :  it  occasions  dulness  on 
percussion,  dyspnoea,  and  cough.  But  the  physical  signs  are  in 
different  situations.  In  one  disorder  they  are  in  the  region  of  the 
heart,  and  are  confined  there ;  in  the  other  they  are  spread  over 
the  whole  side  of  the  chest,  and  are  most  perceptible  at  the 
back.  This  is  true  of  the  dulness,  and,  for  the  most  part,  of  the 
friction  sound,  which,  when  of  pericardial  origin,  is  rarely  heard 
posteriorly. 

At  times,  however,  we  meet  with  very  puzzling  cases.  A  fric- 
tion sound  discerned  over  the  heart  may  be  in  reality  produced 
in  the  adjoining  pleura.  The  patient  is  directed  to  suspend  his 
breathing.  The  friction  sound  does  not  stop.  Now,  the  inference 
from  this  would  be  that  the  sound  originates  in  the  pericardium ; 
and  in  the  large  majority  of  instances  this  is  a  correct  inference. 
But  it  is  not  always  so.  The  friction  may  be  engendered  in  the 
pleura  and  be  caused  by  the  movements  of  the  heart.  To  men- 
tion an  example :  a  laboring-man  was  attacked  with  acute  articu- 
lar rheumatism,  in  the  course  of  which  a  friction  sound  was  heard 
over  the  outer  limit  of  the  left  ventricle,  and  also  posteriorly  over 
the  lower  portion  of  the  left  lung.  Occasionally  it  ceased  when 
the  patient  stopped  breathing,  and  during  a  few  beats  of  the  heart. 
Then  it  recommenced  with  unequal  intensity  while  the  respiration 
was  still  arrested.  It  is  evident  that  this  sound  could  not  have 
been  that  of  an  inflamed  pericardium ;  certainly  the  one  perceived 
anteriorly  was  not.  I  know  of  no  absolute  means,  besides  the  in- 
termission of  the  sound  during  some  of  the  beats  of  the  heart,  of 
detecting  in  these  rare  cases  the  true  seat  of  the  disease. 

To  confound  the  dulness  on  percussion  caused  by  liquid  in  the 
pericardium  with  that  due  to  liquid  in  the  pleura,  is  a  mistake 
more  likely  to  happen,  because  the  two  serous  membranes,  and 
indeed  the  lung,  are  often  implicated  in  the  same  inflammation. 
But  a  pericarditis  uncomplicated  with  pleurisy  or  with  pleuro- 
pneumonia does  not  change  the  clear  sound  at  the  back  of  the 
chest  save  in  very  rare  cases  of  enormous  accumulation  of  fluid. 
Effusion  into  the  pleura  gives  rise  to  a  flat  sound  anteriorly ;  to  a 


382  MEDICAL    DIAGNOSIS. 

still  more  perceptible  dulness  at  the  inferior  portion  of  the  chest 
posteriorly ;  and  the  sounds  of  the  heart  remain  unaltered,  unless 
its  investing  membrane  contain  fluid  also. 

These,  then,  are  the  diseases  with  which  acute  pericarditis  is 
liable  to  be  confounded.  There  are  several  chronic  cardiac  mala- 
dies which  will  occasion  some  of  the  same  signs  and  symptoms : 
such  are  thinning  of  the  ventricles  with  distention  of  the  cavities, 
and  a  dropsy  of  the  pericardium.  But  the  history  of  these  affec- 
tions is  different,  and  their  signs,  although  similar,  are  not  pre- 
cisely the  same.  The  dropsy  of  the  pericardium  is  associated 
with  dropsies  elsewhere,  and  with  some  obvious  cause  accounting 
for  the  watery  exudation,  and  at  no  stage  of  its  existence  does  it 
exhibit  a  friction  sound. 

But  there  is  another  acute  complaint  of  which  pericarditis  some- 
times borrows  the  garb.  The  thoracic  symptoms  may  be  latent, 
but  the  disease  may  produce  the  symptoms  of  extreme  gastric 
irritation  or  inflammation.  There  are  nausea  and  vomiting,  and 
tenderness  on  pressure  in  the  epigastric  region.  All  the  remedies 
are  directed  to  the  stomach ;  and  at  the  post-mortem  examination 
the  physician  stands  amazed  at  finding  this  viscus  healthy  and 
the  pericardium  full  of  serum  or  pus.  An  inquiry  into  the  state 
of  the  heart  might  have  saved  him  from  a  serious  blunder. 

Another  grave  error  which  may  be  thus  obviated  is  the  mis- 
taking of  some  cases  of  acute  pericarditis,  on  account  of  the  wild 
delirium  they  present,  for  acute  inflammation  of  the  brain.  Now, 
both  in  endocarditis  and  in  pericarditis  this  active  delirium  may 
throw  all  the  other  symptoms  into  the  background.  It  is  difficult 
to  see  why  a  pericardial  inflammation  should  give  rise  to  such  vio- 
lent disturbance  of  the  brain.  It  is  not  at  all  unlikely  that  it  has 
its  origin,  in  part,  at  least,  in  the  contaminated  state  of  the  blood 
which  occurs  in  the  affections,  as  rheumatism  or  Bright's  disease, 
with  which  pericarditis  is  often  associated.  However  occasioned, 
it  is  necessary  to  be  aware  that  the  cerebral  symptoms  arising  in 
inflammation  of  the  membranes  of  the  heart  may  entirely  draw 
off  attention  from  the  serious  lesions  within  the  chest.  A  fixed 
delusion  of  having  committed  some  crime  appears  to  Austin 
Flint*  to  be  a  distinguishing  feature  of  the  mental  wandering; 

*  Diseases  of  the  Heart. 


DISEASES    OF    THE    HEAET.  383 

while  Sibson*  in  his  exhaustive  analysis  points  out,  what  I  have 
known  to  happen  in  more  than  one  instance,  that  the  desponding 
and  taciturn,  or,  as  he  calls  it,  sombre  delirium,  lasts  from  two 
or  three  weeks  to  as  many  months. 

Before  dismissing  the  subject  of  pericarditis,  let  us  inquire  in 
how  far  one  of  its  terminations — by  adhesion  or  agglutination  of 
the  surfaces — can  be  recognized.  In  many  of  such  cases,  whether 
or  not  there  be  coexisting  dilatation,  or  hypertrophy,  or  that  rare 
condition,  cardiac  atrophy,  or  even  probably  when  the  heart  is  of 
normal  size,  we  find  changed  rhythm  and  dyspnoea.  Yet  surely 
these  cannot  be  considered  as  special  signs  of  pericardial  adhe- 
sion. Nor  is  the  "  abrupt,  jogging,  or  trembling  motion"  of  the 
heart,  described  by  Hope,  pathognomonic;  nor  the  extinction  of 
the  second  sound,  on  which  Aran  dwells.  For  the  pericardial 
surfaces  may  be  found  most  thoroughly  glued  to  each  other  where 
neither  of  these  signs  was  present.  But  it  must  be  admitted  that 
the  double  jog  is  often  seen,  especially  if  the  enlargement  of  the 
heart  be  at  all  extensive,  and  that  enfeeblement  or  absence  of 
impulse,  while  it  may  happen,  is  much  rarer.  Yet  there  is  not  a 
single  symptom  or  sign  constant,  or  characteristic  of  pericardial 
adhesion.  The  most  trustworthy  signs  are  those  given  by  Skoda  :f 
a  drawing  up  of  the  heart's  apex  during  the  contraction  of  the 
ventricles,  with  a  depression  in  the  intercostal  spaces  becoming 
visible  at  the  same  time,  and  sometimes  with  a  simultaneous  sink- 
ing in  at  the  lower  half  of  the  sternum ;  the  limits  of  the  dull 
jDercussion  sound  remaining  unaffected  during  inspiration  and 
expiration ;  and  a  confused  instead  of  a  distinct  and  punctated 
beat  of  the  impulse  against  the  finger.  Gairdner,J  too,  lays  stress 
upon  the  marked  movement  of  the  intercostal  spaces  over  the 
heart;  while  Walshe§  thinks  that  the  systolic  dimpling  and  the 
undulatory  movements  in  the  prsecordia  only  happen  if  there 
be,  in  addition  to  the  pericardial  adhesions,  pleuritic  adhesions 
in  front  of  the  organ,  or  if  the  agglutination  of  the  pericardium 
be  combined  with  cardiac  hypertrophy.     In  the  latter  case,  too, 


*  Article  "  Pericarditis"  in  Reynolds's  System  of  Medicine. 
f  Zeitsch.  der  k.  k.  Gesellsch.  der  Aerzte  zu  Wien,  April,  1852. 
X  Edinburgh  Medical  Journal,  1851,  1859,  etc. 
\  Diseases  of  the  Heart,  4th  ed.,  p.  244. 


384  MEDICAL    DIAGNOSIS. 

jogging,  trembling  action  of  the  heart  may  be  highly  developed. 
Friedreich*  has  called  attention  to  a  rapid  emptying  of  the  veins 
of  the  neck  during  the  diastole  of  the  heart,  while  with  the  sys- 
tole they  swell  up ;  and  Riess|  has  recently  told  us  that,  owing  to 
the  close  bringing  together  of  the  heart,  diaphragm,  and  stomach, 
the  heart-sounds  resound  with  a  metallic  ring.  When  the  peri- 
cardial surfaces  are  very  extensively  and  firmly  united,  the  eye  is 
struck  by  the  evident  depression  of  the  precordial  region.  When 
the  pericardium  is  adherent  to  the  sternum  and  bands  pass  off 
compressing  the  aorta, — "indurated  mediasti no-pericarditis," — a 
pulse  vanishing  with  each  full  inspiration — pulsus  paradoxus — has 
been  described  by  Kussmaul.J  The  same  sign  has  been  noticed 
by  Irvine  in  cases  of  adherent  pericardium  and  pleura,  and  by 
Traube§  in  exudative  pericarditis  where  the  mediastinum  was 
not  implicated. 

Closely  connected  with  the  subject  of  inflammation  of  the 
pericardium  is  that  rare  affection  in  which  air  is  present  in  the 
pericardial  cavity,  pneumo-pericardium,  or,  more  strictly  speaking, 
on  account  of  the  frequent  association  with  fluid,  pneumo-hydro- 
pericardium.  It  occurs  as  the  result  of  injuries,  of  communication 
established  by  disease  between  the  pericardium  and  the  neigh- 
boring organs,  and  in  very  exceptional  instances  is  due  to  decom- 
position of  liquids  in  the  sac.  Its  chief  diagnostic  features  are 
abnormal  resonance  over  the  cardiac  region,  and  a  metallic  char- 
acter of  the  heart-sounds.  The  tympanitic  resonance  alters  in  a 
most  marked  manner  Math  changes  in  the  posture  of  the  patient, 
and  is  limited  by  a  distinct  line  of  dulness  caused  by  the  fluid. 
The  metallic  sounds  may  at  times  be  heard  at  a  distance,  and  may 
be  attended  with  sounds  of  most  extraordinary  kind  and  combina- 
tion, friction  sounds  mixed  with  splashing  and  gurgling,  the  so- 
called  water-wheel  sound,  the  bruit  de  moidin;  generally  an  inter- 
mittent sound,  at  first  metallic,  which  Reynier||  has  lately  informed 
us  has  not  a  bad  prognostic  meaning,  except  when  the  pericardium 


*  Virchow's  Archiv,  Bd.  xxix. 
f  Berliner  Klinische  "Wochensehrift,  No.  51,  1878. 
%  Ibid.,  No.  37,  1873. 
\  Charite  Annalen,  1876. 
'  ||  Archives  Generates  de  Medecine,  Mai,  1880. 


DISEASES    OF    THE    HEAET.  385 

is  no  longer  intact,  as  in  cases  of  traumatic  opening.  The  symp- 
toms of  pneumopericardium  are  vague  and  ill  defined,  generally 
those  of  a  pericarditis,  with  great  difficulty  in  breathing  and  failing 
circulation.  In  point  of  diagnosis  we  must  be  careful  to  take  all 
the  symptoms  and  signs  into  account,  and  not  be  misled  by  the 
modification  of  the  cardiac  sounds  and  the  splashing  and  metallic 
phenomena  due  to  a  dilated  stomach.  The  entrance  of  air  may 
happen,  as  in  the  cases  of  Meigs*  and  of  Muller,f  by  a  rupture 
brought  about  by  the  pericardial  exudation  ;  in  the  one  case  into 
the  oesophagus,  in  the  other  into  the  lung.  These  cases  of  ulcer- 
ative perforation  almost  all  end  fatally. 

Myocarditis. — The  substance  of  the  heart  itself  undergoes  at 
times  inflammation.  We  can  recognize  such  a  condition  after 
death,  by  the  changed  color,  the  flabbiness,  and  the  presence  of 
granules  of  exudation  and  of  pus-corpuscles  among  the  fibres  of 
the  heart.  It  is  known  that  the  inflammation  may  also  occa- 
sion local  softening  and  circumscribed  abscesses,  and  even  gan- 
grene and  perforation  of  the  ventricle.  But,  though  familiar 
with  the  post-mortem  appearances,  we  are  not  enabled  to  fore- 
tell the  state  of  the  heart  during  life,  mainly  because  the  mus- 
cular structure  is  rarely  affected  without  the  endocardium,  or  still 
more  frequently  the  pericardium,  being  implicated,  and  thus  the 
manifestations  of  these  disorders  occur  mixed  up  with  those  of 
true  carditis. 

On  analyzing  the  cases  on  record,  I  cannot  indeed  find  either 
a  symptom  or  a  sign  which  can  be  considered  as  in  the  least 
pathognomonic.  Extreme  pain  in  the  cardiac  region  is  the  most 
usual  and  the  most  prominent  of  the  symptoms.  It  is  sometimes 
excruciating  and  sharp,  at  other  times  dull,  yet  distressing  and 
constant.  The  breathing  is  generally  much  oppressed;  delirium 
is  often  present;  the  skin  becomes  cold ;  the  heart  fails  in  power; 
and  the  patient  dies  in  a  state  of  utter  prostration  or  appears  to 
suffocate.  The  pulse,  as  in  endocarditis  or  in  pericarditis,  exhibits 
no  uniform  character.  The  statement  that  it  is  invariably  inter- 
mittent, feeble,  and  quick,  is  not  correct.  It  is  so  as  the  disease 
advances,  but  it  has  been  reported  to  be  full,  and  not  above  eighty, 


*  Amer.  Journ.  of  Med.  Sci.,  Jan.  1875. 
f  Deutsches  Archiv  fur  Klinische  Medicin,  Bd.  xxiv.,  1879. 
25 


386  MEDICAL    DIAGNOSIS. 

long  after  the  distress  in  the  chest  was  unbearable.*  Extreme 
rapidity  with  great  weakness  of  the  pulse  is,  a  careful  observerf 
has  told  us,  probably  the  most  trustworthy  sign  of  acute  myocar- 
ditis when  extensive  and  diffuse. 

The  diagnosis  of  diffuse  chronic  myocarditis  is  as  uncertain  as 
of  the  acute  form.  The  symptoms  are  those  of  a  weak  heart; 
oedema,  dyspnoea,  hemorrhages  into  different  organs,  venous  con- 
gestions, have  been  especially  noted.  The  first  sound  is  indistinct, 
the  second  over  the  aorta  very  weak.  The  most  characteristic 
sign  is  a  want  of  correspondence  between  the  heart  and  the  pulse- 
beats  ;  these  are  unequal  and  irregular.^ 

Chronic  Diseases  attended  with  Increased  Extent  of  Percus- 
sion Dulness,  but  with  Normal  or  almost  Normal  Heart- 
Sounds. 

We  often  meet  with  a  group  of  affections  which  present  the 
phenomena  of  extended  dulness  on  percussion  in  the  cardiac 
region,  associated  with  sounds  like  those  heard  in  health :  they 
may  be  louder  or  less  loud,  better  defined  or  less  well  defined,  still 
they  are  the  natural  sounds  of  the  heart,  and  no  cardiac  murmur 
is  detected,  unless  the  disorder  be  no  longer  uncomplicated. 

To  this  group  belong  those  diseases  which  affect  the  walls  of 
the  heart  or  its  cavities,  without  having  involved  the  valvular 
apparatus,  such  as  hypertrophy  and  dilatation, — types  of  the  two 
different  states  of  force  and  of  weakness,  but  both  exhibiting  an 
extent  of  percussion  dulness  greater  than  in  health,  and  heart- 
sounds  not  materially  changed. 

Hypertrophy. — Hypertrophy  of  the  heart  is  an  overgrowth 
of  its  walls,  and  usually  also  of  its  cavities ;  for,  although  we  may 
have  the  muscle  thickening  without  the  cavity  enlarging,  nay,  even 
with  its  diminishing  in  size,  neither  this  simple  nor  the  concentric 


*  Salter,  Medico-Chirurgical  Transactions,  vol.  xxii.  In  several  of  the 
cases  on  record,  for  instance  in  the  one  mentioned  hy  Graves  in  his  Clinical 
Lectures,  there  was  coexisting  valvular  disease,  which,  of  course,  invalidates 
the  statements  as  regards  the  character  of  the  pulse,  and  indeed  as  regards 
many  of  the  other  symptoms. 

f  Fothergill,  Diseases  of  the  Heart,  2d  ed.,  1879. 

X  Kuhle,  Archiv  fur  Klin.  Med.,  1878. 


DISEASES    OF    THE    HEAET.  387 

hypertrophy  occurs,  save  in  rare  instances.  It  is  evident  that  any 
one  of  the  chambers  of  the  heart  may  alone  become  hypertrophied. 
But,  practically,  the  state  we  mean  when  speaking  of  cardiac  hyper- 
trophy is  an  increase  of  the  ventricles,  and  especially  of  the  left 
ventricle,  in  its  wall  and  cavity,  with  a  similar,  although  much 
slighter,  expansion  of  the  right  side.  Whether  the  auricles  be 
enlarged  or  not,  is  a  matter  always  more  of  conjecture  than  sus- 
ceptible of  proof. 

The  physical  and  vital  manifestations  of  the  heart  having  out- 
grown its  natural  dimensions  are  these.  The  pulse  is  full  and 
strong,  and  somewhat  tense.  The  face  is  florid,  or  else  it  is  pale ; 
and  the  mucous  membranes  of  the  lips  and  eyelids  are  injected. 
The  eyes  are  bright,  and  apt  to  be  prominent.  The  carotids  pul- 
sate forcibly  under  the  least  excitement.  Some  persons  suffer 
from  headache  and  giddiness;  in  fact,  all  the  symptoms  denote  a 
circulation  actively,  too  actively,  carried  on.  Yet  the  symptoms 
directly  referable  to  the  heart  are  not  marked.  There  is,  as  a  rule, 
no  pain  or  irregular  action  of  the  heart,  nor  do  violent  fits  of 
palpitation  occur.  What  the  patient  comes  to  consult  his  physi- 
cian about,  are  rushes  of  blood  to  the  head;  or  a  ringing  in  the 
ears;  or  a  feeling  of  weight  in  the  epigastrium  which  troubles 
him  after  a  full  meal ;  or  shortness  of  breath ;  or  in  consequence 
of  the  powerful  action  of  the  heart,  when  lying  in  bed,  attracting 
his  attention ;  or  because  he  is  alarmed  about  a  dry  cough,  and 
believes  himself  the  victim  of  pulmonary  consumption. 

The  physical  signs  are  more  uniform  than  the  symptoms.  We 
observe  a  fulness  or  arching  of  the  precordial  region,  and  an 
impulse,  strong,  heaving,  and  extended  over  several  intercostal 
spaces.  The  apex  does  not  strike  the  chest-walls  between  the  fifth 
and  sixth  ribs,  but  its  beat  is  perceived  lower  down,  and  more  in- 
ward, toward  the  median  line,  in  consequence  of  the  enlarged  and 
weighty  heart  not  retaining  its  normal  position.  The  extent  of 
percussion  dulness  increases,  both  longitudinally  and  transversely; 
and  particularly  in  the  latter  direction,  if  the  right  ventricle  be 
much  enlarged.  This  peculiarity  in  the  expansion  of  the  area  of 
dulness  on  percussion  forms,  in  truth,  with  the  greater  dyspnoea, 
and  with  an  impulse  more  directly  perceived  over  the  right  side  of 
the  heart,  near  the  pit  of  the  stomach,  and  often  out  of  proportion 
to  the  compressible  and  rather  small  radial  beat,  and  with  the 


388 


MEDICAL    DIAGNOSIS. 


increased  distinctness  of  the  second  sound  of  the  pulmonary  artery, 
the  sign  that  hypertrophy  with  dilatation  has  principally  affected 
the  right  side. 

The  first  sound  of  an  hypertrophied  heart  is  duller  than  in 
health,  but  prolonged  and  weighty.  The  second  sound  is  not 
particularly  changed.  There  are  no  murmurs,  except  under  rare 
circumstances,  which  will  be  alluded  to  in  discussing  valvular  dis- 
eases.   Thus,  the  greatest  value  of  auscultation  is,  that,  by  showing 

Fig.  33. 


O^VM^V-Vt^ 


An  hypertrophied  heart  lying  in  its  position  in  the  chest.  The  cause  of  the 
lowered  apex  beat,  and  of  the  extension  of  the  impulse,  as  well  as  of  the 
somewhat  sqnarer  ontlino  of  the  increased  dulness  over  the  enlarged  organ, 
is  obvious  from  the  shape  and  position  of  the  heart. 


us  that  the  sounds  are  but  little  altered,  it  enables  us  positively 
to  exclude  a  lesion  of  the  valves ;  just  as  the  chief  service  of  per- 
cussion, with  reference  to  an  enlarged  heart,  consists  in  permitting 
us  to  distinguish  the  excited  motions  of  the  simply  disturbed  organ 
from  the  action  of  a  heart  the  walls  of  which  are  thickened  ;  and 
as  the  main  use  in  noting  the  impulse  is  that  it  serves  as  a  means 
of  discrimination   between   hypertrophy  and   those  affections  in 


DISEASES    OF    THE    HEAKT.  389 

which  the  beat  is  weakened,  such  as  dilatation,  or  a  pericardial 
effusion,  or  between  the  dulness  in  the  precordial  region  due 
to  hypertrophy  and  that  caused  by  deposits  in  the  pleura  or  the 
lung. 

Hypertrophy  may  be  combined  with  dilatation  of  the  heart. 
This  hypertrophy  with  dilatation  presents  a  less  dull,  prolonged 
first  sound,  and  the  pulse,  though  full,  is  likely  to  be  more  com- 
pressible. Hypertrophy  may  affect  specially  any  part  of  the  con- 
stituents of  the  muscular  walls.  Thus,  the  connective  tissue,  as 
Quain  has  specially  called  attention  to,  may  be  alone  concerned  in 
the  morbid  action.  Hypertrophy  of  the  heart  is  found  much 
more  frequently  among  males  than  "among  females.  Its  causes  are 
various.  It  is  common  in  Bright's  disease ;  continued  functional 
excitement  produces  it ;  so  does  any  kind  of  strain  and  overaction, 
and  perhaps  excessive  nourishment.  But  the  main  cause  is  an 
obstruction  to  the  circulation,  either  in  the  heart  or  in  other  organs. 
It  is  for  this  reason  that  the  complaint  is  so  often  met  with  in  con- 
nection with  diseases  of  the  valves  or  of  the  large  arteries,  and 
that  the  right  side  of  the  heart  enlarges  when  the  pulmonary  air- 
vesicles  are  overdistended.  We  also,  as  we  have  seen,  encounter 
hypertrophy  of  the  heart  as  a  consequence  of  the  obliteration  of 
the  pericardial  sac  by  its  two  surfaces  adhering. 

There  is  a  form  of  hypertrophy  of  the  heart  to  which  attention 
has  been  particularly  called  by  Fothergill's  admirable  description, 
— the  so-called  gouty  heart.  Generally,  although  not  always,  there 
is  coexisting  disease  of  the  kidney  of  the  chronic  contracting  form. 
In  the  first  stage  of  the  affection,  when  well  marked,  we  find  de- 
cided hypertrophy  with  accentuation  or  booming  of  the  second 
aortic  sound,  high  blood-pressure,  tense  pulse,  hardened  arteries, 
and  the  passage  of  large  amounts  of  pale  urine  of  low  specific 
gravity.  The  renal  changes  may  or  may  not  be  evident;  we  may 
or  may  not  detect  albumen  in  the  urine.  In  a  subsequent  stage  of 
the  malady  there  is  failure  of  the  circulation,  and  with  the  signs 
of  the  heart-failure,  very  often  going  hand  in  hand  with  fatty 
degeneration,  the  bulk  of  urine  diminishes  and  the  renal  affection 
becomes  more  marked.  The  cardio- vascular  phenomena  are  early 
made  perceptible  by  the  sphygmograph.  The  full,  tense  pulse 
gives  a  full  ups-troke,  a  broad  summit,  and  a  retarded  down- 
stroke  ;  the  "  square-headed  tracing"  formed  is  very  characteristic 


390  MEDICAL    DIAGNOSIS. 

of  the  malady,  and  bespeaks  the  fibroid  change  in  the  kidney, 
whether  or  not  albumen  be  found.  In  some  instances  there  is 
considerable  dilatation  as  well  as  hypertrophy,  and  then  severe 
palpitations  result.  The  high  blood-pressure  is  due  to  the  waste- 
laden  blood ;  and  the  defective  nutrition  is  apt  to  show  itself  also 
in  atheromatous  arteries,  which  in  part  account  for  the  sphygmo- 
graphic  tracings.  The  skin  often  exhibits  little  twigs  of  dilated 
vessels;  the  ear  is  usually  deep  red,  with  a  large  glistening  lobe; 
or  in  spare  persons  the  lobe  looks  withered ;  the  teeth  become 
blunt  and  worn  down  in  time ;  the  hair  is  apt  to  be  iron-gray. 
There  is  the  history  of  gout,  acquired  or  hereditary,  but  there  may 
have  been  no  active  outbreak  of  gout,  but  rather  the  condition  of 
imperfect  assimilation  and  increased  uric  acid  or  urates,  known  as 
lithiasis. 

Dilatation. — Dilatation  of  the  heart  is  the  reverse  of  hyper- 
trophy. By  this  it  is  not  meant  that  because  the  cavities  are  dilated 
the  walls  may  not  be  increased.  But  it  is  meant  that  the  morbid 
condition  in  which  the  cavities  have  been  stretched  out  of  all  pro- 
portion to  the  thickness  of  the  muscular  walls  is  the  reverse  of 
the  condition  in  which  the  walls  are  stronger,  firmer,  and  more 
powerful  than  in  health  ;  in  other  words,  the  latter  state  is  very 
different  from  the  former,  and  when  it  predominates  we  call  the 
affection  hypertrophy ;  when  the  former  is  in  excess  we  speak  of 
the  disease  as  dilatation,  no  matter  whether  the  walls  be  slightly 
thicker  than  normal,  or  of  natural  thickness,  or,  as  they  often  are, 
thinner,  and  apparently  hardly  capable  of  supporting  the  weight 
of  the  blood. 

From  these  almost  opposite  pathological  states,  almost  opposite 
physical  signs  or  symptoms  might  be  expected.  And  so  we  find 
it.  In  dilatation  we  look  in  vain  for  the  activity  and  power  with 
which  the  blood  is  forced  out  of  an  hypertrophied  heart.  Every- 
thing indicates  debility,  inaction,  and  stagnation  of  the  vital  cur- 
rent. There  is  a  strong  tendency  to  venous  congestions  and  to 
dropsies.  The  portal  system  is  gorged.  The  liver  increases  in 
size.  The  bowels  are  constipated.  The  urinary  secretion  is  inter- 
fered with,  and  sometimes  albumen  is  passed.  The  hearing  may 
become  dull.  The  patient  is  languid  and  feeble,  and  his  intellect 
obtuse.  He  suffers  from  chilly  sensations,  and  from  distressing 
palpitations  and  uneasiness  in  the  cardiac  region.     The  pulse  is 


DISEASES    OF    THE    HEART. 


391 


small  and  irregular,  and  the  veins  of  the  surface  are  swollen.  The 
skin  around  the  ankles,  and  often  at  other  parts  of  the  body,  pits 
on  pressure.  But,  since  it  is  the  right  side  of  the  heart  which  is 
usually  the  most  affected,  the  lungs  show  most  plainly  the  effects 
of  the  venous  stagnation.  Difficulty  in  breathing,  making  itself 
at  times  manifest  in  paroxysms  attended  with  wheezing  respira- 
tion ;  a  chronic  cough ;  a  collection  of  serum  in  the  pulmonary 
structure, — all  add  to  the  misery  which  this  perilous  malady 
entails.     And  as  it  is  commonly  some  obstructive  disease  in  the 

Fig.  34. 


A  dilated  heart,  the  right  ventricle  opened.  In  this  case  there  was 
no  valvular  disease.  Hence  the  characteristic  phj'sical  signs ;  the  in- 
creased dulness  on  percussion,  the  extended  but  weak  impulse.  The  first 
sound  was  feeble,  for  the  organ  was  soft  as  well  as  dilated. 


lungs,  such  as  emphysema,  which  has  given  rise  to  the  dilatation 
of  the  right  side  of  the  heart,  so  this  again  augments  the  morbid 
state  of  the  lungs,  and  aggravates  the  symptoms. 

The  physical  signs  are  very  unlike  those  of  hypertrophy.  The 
same  extended  dulness  on  percussion  exists ;  but  it  is  associated 
with  a  feeble  and  fluttering  impulse,  which  is  in  strong  contrast 
with  the  heaving,  powerful  blow  of  an  hypertrophied  left  ventricle. 


392  MEDICAL    DIAGNOSIS. 

The  sounds  are  not  always  the  same.  When  the  walls  are  thin, 
they  are  clearer,  sharper,  and  more  ringing  than  in  health  :  if, 
however,  the  muscular  structure  be  at  all  disorganized,  the  first 
sound  is  faint  and  very  ill  defined.  But  no  murmurs  are  per- 
ceived, unless  a  watery  state  of  the  blood  produces  them,  or 
unless  it  happens — and  it  does  not  unfrequently  happen — that 
the  dilatation  of  the  heart  is  conjoined  to  valves  incompetent, 
either  temporarily  or  permanently,  to  prevent  regurgitation. 

Such  is  the  description  of  cases  of  marked  dilatation.  All  cases 
are  not,  however,  so  distinct,  nor  are  they  uncomplicated.  Or- 
ganic affections  of  the  heart  are,  indeed,  indefinitely  blended,  and 
dilatation  is  met  with  in  different  combinations  and  in  every  pos- 
sible degree.  Accordingly,  its  symptoms  and  signs  are  somewhat 
dissimilar.  But  one  constant  feature  it  certainly  preserves :  it 
always  holds  up  to  view  both  the  vital  and  the  physical  manifes- 
tations of  a  weak  heart.  It  is  thus  that  it  is  likely  to  be  con- 
founded with  the  diseases  in  which  enfeebled  action  of  the  heart 
is  encountered,  and  these  are  fatty  degeneration  and  a  pericardial 
effusion. 

Fatty  Degenei-ation. — This  is  one  of  those  disorders  with  the 
anatomical  characters  of  which  we  are  far  better  acquainted  than 
with  their  clinical  history.  The  microscope  has  revealed  to  us 
that  the  soft,  flabby  heart,  which  appears  to  the  eye  little  changed 
from  health,  has  had  its  muscular  fibres  atrophied  and  trans- 
formed into  fat-granules  and  oil.  It  has  thus  explained  to  us, 
what  was  previously  incomprehensible,  why  a  heart  seemingly  so 
little  altered  should  rupture,  or  why  death  should  set  in  with  all 
the  evidences  of  failing  circulation,  when  nothing  in  the  whole 
body  can  be  found  sufficiently  diseased  to  account  for  the  termina- 
tion of  the  vital  action.  But  our  power  to  recognize  the  fatty 
change  during  life  has  not  kept  pace  with  our  power  to  recognize 
it  after  death.  There  is  as  yet  no  sign  discovered  by  which  we 
can  positively  say  that  the  dangerous  disorganization  of  the  mus- 
cular fibres  of  the  heart  is  in  progress.  We  may,  however,  sus- 
pect it,  if  the  signs  of  weak  action  of  the  heart — feeble  impulse 
and  ill-defined  sounds — coexist  with  oppression,  with  a  tendency 
to  coldness  of  the  extremities,  with  a  pulse  permanently  slow  or 
permanently  frequent  and  irregular,  and  be  met  with  in  a  person 
who  is  the  subject  of  gout  or  of  a  wasting  disease,  or  is  very  in- 


DISEASES    OF    THE    HEART.  393 

temperate,  or  has  arrived  at  a  time  of  life  at  which  all  the  organs 
are  prone  to  undergo  decay.  Something  more  than  a  suspicion  is 
warranted,  if,  in  addition,  there  be  proof  of  atheromatous  change 
in  the  vessels,  or  of  fatty  degeneration  elsewhere,  such  as  an 
arcus  senilis  ,**  or  if  it  be  ascertained  that  the  patient  suffers  from 
pain  across  the  upper  part  of  the  sternum  and  from  paroxysms 
of  severe  pain  in  the  heart;  that  he  sighs  frequently;  that  he 
is  easily  put  out  of  breath ;  that  his  skin  has  a  yellow,  greasy 
look;  that  he  is  subject  to  syncope,  or  to  seizures  during  which 
his  respiration  seems  to  come  to  a  stand-still ;  and  that  he  is 
liable  to  vertigo,  or  to  be  stricken  down  with  repeated  attacks 
having  the  character  of  apoplexy,  save  that  they  are  not  followed 
by  paralysis. 

Now,  here  are  certainly  a  group  of  phenomena  dissimilar  to 
those  of  a  dilated  heart.  Let  us  add  that  the  extent  of  the  cardiac 
percussion  dulness  remains  unaltered,  except  in  those  instances  in 
which  some  hypertrophy  coexists,  that  dropsies  and  local  conges- 
tions are  not  prominent  symptoms,  or  indeed  do  not  happen  at 
all,  and  the  dissimilarity  becomes  still  greater.  A  differential 
diagnosis  would,  under  such  circumstances,  be  anything  but  diffi- 
cult. But  in  point  of  fact  the  matter  is  generally  not  so  easily 
decided,  and  there  are  several  reasons  why  it  is  not.  One  is,  that 
all  the  features  described  are  rarely  combined  in  the  same  case; 
indeed,  some  of  the  more  marked,  such  as  the  peculiar  respiration, 
the  seizures  like  apoplexy,  are  uncommon  rather  than  common, 
and  the  altered  breathing  occasionally  occurs  in  other  cardiac 
maladies.f  The  second  is,  because  non-fatty  softening  may  present 
the  same  vital  and  physical  manifestations.    The  third  is,  because 

*  But  the  exact  relation  which  the  arcus  senilis  hears  to  a  fatty  heart  is  not 
definitely  ascertained.  It  certainly  may  be  absent.  Fothergill  points  out 
that  there  is  a  true  and  a  false  arcus.  The  former  alone  is  significant  of  fatty 
degeneration  and  tissue-decay.  It  is  a  ring  around  the  cornea  of  yellowish 
hue  with  blurred  outlines,  and  the  cornea  itself  is  cloudy.  The  false  form 
occurs  in  elderly  persons  as  an  evidence  of  calcareous  degeneration  ;  the  ring 
is  well  defined,  the  central  part  of  the  cornea  is  clear  and  bright. 

f  The  altered  breathing  alluded  to,  or  the  "  Cheyne-Stokes  respiration,"  is 
certainly,  leaving  out  even  other  than  cardiac  affections,  not  limited  to  fatty 
heart.  Hayden  (Diseases  of  the  Heart)  advances  the  view  that  it  is  always 
associated  with  atheromatous  or  calcareous  change,  and  with  dilatation  of  the 
arch  of  the  aorta. 


394  MEDICAL    DIAGNOSIS. 

a  fatty  heart  has  a  tendency  to  become  dilated,  and  the  symptoms 
and  signs  of  the  former  disease  are  then  merged  into  the  symptoms 
and  signs  of  the  latter,  throwing  ns  back  for  a  diagnosis  into  the 
province  of  conjecture  and  probability.  With  the  organ  in  such 
a  condition,  the  practical  value  of  a  differential  diagnosis  is,  how- 
ever, not  great;  for  both  affections  are  benefited  by  the  same 
treatment :  both  require  that  the  power  of  the  heart  should  not 
be  lowered,  and  that  the  blood  should  be  enriched.  It  is  hardly 
necessary  to  add  that  all  causes  of  serious  excitement  are  to  be 
strenuously  guarded  against. 

The  remarks  about  fatty  heart  apply  particularly  to  that  variety 
of  the  disorder  in  which  the  muscular  structure  in  middle-aged  or 
elderly  persons  has  slowly  undergone  decay.  But  we  also,  although 
far  less  frequently,  meet  with  fatty  heart  in  young  persons  and  in 
a  more  acute  form ;  we  encounter  it  in  chlorosis,  in  pernicious 
anaemia,  after  repeated  hemorrhages,  therefore  when  the  blood  is 
profoundly  altered,  also  after  phosphorus  poisoning.  Poisonous 
doses  of  acids,  such  as  nitric,  sulphuric,  oxalic,  are  said  by  Von 
Dusch  also  to  give  rise  to  the  cardiac  change. 

Persons  who  have  fatty  hearts  are  subject  to  attacks  of  faint- 
ness,  preceded  or  attended  with  sensations  of  great  coldness,  or  a 
chill.  Sometimes  these  attacks  happen  daily,  or  every  few  days, 
and  in  such  a  manner  as  to  give  rise  to  the  impression  that  they 
are  due  to  malaria.  A  number  of  instances  of  the  kind  have  come 
under  my  observation,  and  I  have  met  with  them  particularly  at 
the  end  of  fevers  or  other  debilitating  diseases  happening  in  those 
affected  with  feeble  hearts.  The  seizures,  though  bearing  a  resem- 
blance to  intermittent  fever,  are  unlike  it  in  being  associated  with 
signs  of  great  weakness  of  the  circulation,  with  sometimes  almost 
a  vanishing  pulse  and  a  sense  of  impending  dissolution  ;  in  their 
irregular  accession;  and  in  their  not  being  followed  by  febrile 
phenomena.  In  doubtful  cases  the  thermometer,  by  showing  the 
absence  of  the  great  rise  of  temperature  of  the  malarial  disorder, 
will  materially  assist  us  in  the  diagnosis. 

A  fatty  heart  sometimes  ruptures.  Xow,  in  spite  of  the  care 
with  which  some  authors  have  detailed  the  physical  signs  of  this 
mishap,  we  know  nothing  positively  about  them ;  for  death 
usually  takes  place  far  too  rapidly  to  permit  of  any  such  obser- 
vations.    The  symptoms  that  are  mostly  noticed  are  these :   the 


DISEASES    OF    THE    HEAKT.  395 

patient  is  suddenly  attacked  with  intolerable  anguish  in  the  heart ; 
he  presses  his  hand  to  it,  then  faints,  and  soon  expires.  Or  else 
he  lives  for  a  short  time,  suffering  from  faintness,  cramps,  and 
difficulty  of  breathing,  and  with  death  plainly  written  on  his 
face. 

Where  there  is  fatty  accumulation  on  the  heart,  without  fatty 
change  of  its  fibres, — a  condition  we  sometimes  find  in  persons 
whose  internal  viscera  are  loaded  with  fat, — the  manifestations  are 
those  of  a  feeble  heart,  and  different  from  fatty  degeneration  only 
in  degree.  The  first  sound  of  the  heart  is  weak  and  toneless;  the 
pulse  is  feeble,  but,  as  Walshe  tells  us,  regular.  The  percussion 
dulness  in  the  cardiac  region  is  somewhat  increased.  A  sensation 
of  oppression  over  the  region  of  the  heart,  or  even  actual  pain,  is 
complained  of. 

Atrophy  of  the  heart  is  so  rare  a  condition  that  its  symptoms  are 
scarcely  understood.  All  we  know  is  that  at  times  in  certain 
wasting  diseases,  such  as  tubercular  phthisis  and  suppurating  bone 
affections,  the  heart  atrophies ;  it  may  also  do  so  when  the  coronary 
arteries  are  calcified,  or  the  pericardium  is  tightly  adherent;  and 
cardiac  atrophy  is  said  to  happen  occasionally  after  pregnancy  and 
chlorosis.  It  has  not  a  single  symptom  nor  a  single  sign  by 
which  it  can  be  recognized  with  certainty.  Theoretically,  the 
diminished  j^ercussion  dulness,  clear  sounds,  and  feeble  impulse 
should  enlighten  us,  but,  even  in  cases  where  there  is  no  coexisting 
fatty  change,  they  are  too  uncertain  to  be  made  a  basis  for  diag- 
nosis, or  attending  lung  conditions  throw  doubt  on  several  of 
them.  There  is  great  tendency  to  palpitation,  and  the  pulse, 
Hayden  tells  us,  is  quick,  all  but  inappreciable,  yet  regular. 

Pericardial  Effusion. — Pericardial  effusion  also  presents  the 
signs  of  a  weakened  heart  with  increased  dulness  on  percussion 
in  the  cardiac  region,  and  is  thus  very  liable  to  be  mistaken  for  a 
dilatation  of  the  organ.  Where  the  effusion  forms  part  of  a  gen- 
eral dropsy,  the  detection  of  the  cause  of  the  latter,  in  connection 
with  the  different  signs  which  fluid  in  the  pericardium  occasions, 
will  prevent  error.  Where  the  liquid  has  remained  after  an  inflam- 
mation of  the  membrane,  both  signs  and  symptoms  are  like  those 
of  the  state  of  effusion  in  acute  pericarditis,  and  although  there 
are  points  of  resemblance  to  a  dilated  heart,  there  are  also  points 
of  contrast,  as  the  subjoined  table  shows : 


396  MEDICAL    DIAGNOSIS. 

_^  TT  Chronic  Pericarditis  with 

Dilatation  of  the  Heart.  _, 

Effusion. 

Percussion  dulness  increased  in   ex-     Percussion  dulness  increased,  but  of- 

tent,  but  square  in  outline.  ten  of  pyramidal  shape. 

Heart-sounds  clear  and  sharp ;  some-  Heart-sounds  feeble  and  distant- 
times,  however,  feeble.  sounding  at  the  apex,  but  distinct 

near  the  upper  part  of  the  sternum. 
No  friction  sound.  Often  friction  sound  still  heard  at  the 

base  of  the  heart. 
Dropsy  ;  signs  of  venous  stagnation  ;     Neither  dropsy  nor  venous  stagnation 
severe  cough,  and  dyspnoea.  is  observed;  or,  if  at  all,  only  in  a 

very  limited  degree.      Cough   and 
dyspnoea   are  not   such   prominent 
symptoms. 
History   of   disease   shows    it    to   be     The  history  frequently  points  to  the 
gradually  developed.  acute  attack. 

These,  then,  are  the  marks  of  distinction  presented  by  a  chronic 
pericardial  effusion,  a  fatty  heart,  and  cardiac  dilatation ;  in  other 
words,  between  the  morbid  states  which  occasion  the  signs  and 
symptoms  of  a  feebly-acting  heart.  Before  proceeding,  let  us 
glance  at  one  more  condition,  fortunately  infrequent,  which  may 
give  rise  to  some  of  the  same  phenomena  as  those  described, — an 
accumulation  of  blood  in  the  cavities  of  the  heart.  Like  dilatation, 
this  increases  the  area  of  percussion  dulness,  and  is  often  asso- 
ciated with  perverted  rhythm.  The  chief  differences,  as  far  as  our 
limited  knowledge  of  the  subject  permits  us  to  define  them,  are 
these:  the  impulse  is  generally  much  more  labored  and  irregular, 
is  sometimes  strong,  sometimes  weak,  not  so  almost  uniformly 
indistinct  or  tremulous.  There  is  much  more  venous  congestion 
of  the  face,  with  greater  dyspnoea,  and  we  often  find  some  acute 
malady,  such  as  endocarditis  or  pneumonia,  giving  rise  to  the 
cardiac  engorgement.  But  the  matter  is  often  a  very  difficult  one 
to  determine;  for  many  of  the  same  states  which  lead  to  dilatation 
may  produce  an  accumulation  of  blood  in  the  heart;  nay,  dilata- 
tion itself  predisposes  to  it. 

Diseases  of  the  Heart  exhibiting  more  or  less  of  the  Signs 
and  Symptoms  of  Enlargement  of  the  Organ,  and  accom- 
panied by  Endocardial  Murmurs. 

Valvular  Affections. — To  find  the  sounds  of  the  heart 
clearly  and  well  defined,  is  to  know  that  no  disease  of  the  valves 


DISEASES    OF    THE    HEART.  397 

exists.  No  matter  whether  there  be  reason  to  believe  that  the 
Avails  of  the  heart  are  hypertrophied  to  twice  their  thickness  or 
the  cavities  stretched  to  twice  their  capacity,  if  the  ear  recognize 
the  natural  sounds  it  is  evidence  that  the  valvular  apparatus  is 
not  affected.  When  it  is  disordered,  the  mischief  betrays  itself, 
for  the  most  part,  by  a  blowing  sound.  If,  therefore,  a  murmur 
of  any  permanence  be  met  with  in  the  heart,  if  especially  it  be 
associated  with  the  signs  of  either  hypertrophy  or  dilatation,  the 
inference  that  valvular  disease  exists  will  in  the  vast  majority  of 
cases  be  a  correct  inference. 

Yet  it  will  not  be  so  always  ;  for  there  are  other  morbid  states 
besides  valvular  affections  which  engender  a  murmur,  that  may 
be  even  accompanied  by  all  the  manifestations  of  enlargement  of 
the  heart.  Malformations,  such  as  communications  between  the 
auricles  or  between  the  ventricles,  or  between  the  great  vessels 
near  their  origin,  or  impoverished  blood,  or  a  misdirected  blood- 
current,  may  occasion  a  murmur. 

Xow,  with  reference  to  malformations,  their  presence  in  adults, 
or  in  children  that  have  passed  the  days  of  infancy,  is  exceedingly 
rare.  The  most  trustworthy  symptom  they  present  is  that  which 
indicates  the  admixture  of  arterial  and  of  venous  blood ;  in  other 
words,  the  symptom  of  cyanosis,  the  bluish  discoloration  of  the 
skin.  In  addition,  we  may  perceive  the  signs  of  disturbed  circu- 
lation in  the  lungs,  such  as  dyspnoea  and  cough ;  and  of  irregular 
action  of  the  heart;  and  a  blowing  sound  in  the  cardiac  region. 
Still,  the  recognition  of  these  malformations  is  always  more  or  less 
a  matter  of  conjecture,  and  to  mistake  them  for  other  organic 
changes  in  the  heart,  particularly  those  of  the  valves,  is  a  mistake 
which  in  the  actual  state  of  our  knowledge  cannot  be  avoided. 
With  the  aid  of  more  such  researches  as  those  of  Moreton  Stille* 
and  of  Peacock,!  we  shall  become  accurately  acquainted  with  the 
pathology  of  the  different  lesions,  and  perhaps  ultimately  be  able 
to  discern  them  with  certainty  during  life.  At  present  it  is  in  their 
rarity  that  the  safety  against  errors  of  diagnosis  lies.  A  curious 
result  of  cardiac  malformation  has  been  recently  pointed  out, — 
abscess  of  the  brain  without  appreciable  cause.! 

*  American  Journal  of  the  Medical  Sciences,  July,  1844. 

t  Treatise  on  Malformations  of  the  Heart. 

X  Ballet,  Archives  Generales  de  Medecine,  Juin.  1S80. 


398  MEDICAL    DIAGNOSIS. 

As  a  few  points  of  assistance  may  be  mentioned  that  communi- 
cation of  the  ventricles  through  the  septum  gives  rise  to  a  systolic 
murmur  at  or  near  the  base  of  the  heart  not  propagated  into  the 
arteries;  that  the  passage  of  blood  through  an  open  foramen  ovale 
very  rarely  engenders  any  sound ;  and  that,  whether  coexisting 
with  these  lesions  or  not,  the  majority  of  instances  of  cardiac  mal- 
formation, after  the  age  of  twelve,  present  signs  of  obstruction  at 
the  orifice  of  the  pulmonary  artery.  In  this  instance  either  a 
systolic  or  a  diastolic  murmur  may  be  there  perceived ;  in  the 
first  case  the  second  sound  of  the  heart  is  weak  or  wanting  in 
the  second  interspace  on  the  left  side. 

The  resemblance  borne  by  cases  of  functional  disturbance  of  the 
heart,  associated  with  impoverished  blood,  to  valvular  affections, 
has  already  engaged  our  attention.  The  age ;  the  appearance  of 
the  patient;  the  seat  of  the  blowing  sound  at  the  base  of  the 
heart;  the  venous  hum  ;  the  fact  that  the  cardiac  murmur  is  fol- 
lowed by  a  sharp  second  sound, — all  are  points  upon  which  some 
stress  may  be  laid;  yet  not  so  much  as  upon  the  absence  of  the 
phenomena  of  an  enlarged  heart.  But  if  the  question  be  asked, 
Are  the  latter  absolute  demonstrations  of  the  existence  of  an  affec- 
tion of  the  valves?  cannot  a  hypertrophied  or  dilated  heart,  with 
sound  valves,  be  combined  with  a  condition  of  blood  capable  of 
producing  a  murmur? — we  are  forced  to  answer  that  such  is 
possible.  Under  these  circumstances,  the  tact  of  the  physician 
may  help  him  to  a  well-judged  decision ;  but  the  only  proof  of  a 
well-judged  decision  is  afforded  by  time  or  by  the  result  of  the 
treatment  which  restores  the  blood  to  its  normal  state. 

A  murmur  caused,  in  violent  excitement  of  the  heart,  by  mis- 
direction of  the  current,  due  chiefly  to  temporary  interference  with 
the  closure  of  the  valves,  or,  perhaps,  owing  to  altered  tension  of 
the  valves, — causes  the  exact  working  of  which  I  have  elsewhere 
inquired  into,* — may  become  a  troublesome  source  of  error  in 
diagnosis,  especially  when  heard  over  a  heart  in  a  state  of  dilated 
hypertrophy  or  of  dilatation.  Fortunately,  a  blowing  sound  of 
this  origin  and  in  this  combination  is  comparatively  rare,  and  we 
are  enabled  to  discriminate  it  from  an  organic  valvular  murmur 
by  its  not  being  persistent.     It  is  much  more  likely  to  be  heard  at 

*  On  Functional  Valvular  Disorders,  Amer.  Journ.  Med.  Sci.,  July,  1869. 


DISEASES    OF    THE    HEAET.  399 

the  apex,  or  rather,  according  to  my  own  observations,  somewhat 
above  the  apex,  than  is  a  murmur  owing  to  changes  in  the  blood ; 
and  it  differs  from  the  systolic  blowing  sound  of  mitral  disease 
partly  by  the  peculiarity  of  seat  just  mentioned,  partly  by  its 
non-diffusion,  its  usual  absence  at  the  back  of  the  chest,  the 
want  of  harshness  in  the  inconstant  murmur,  and  the  low  pitch. 
Murmurs  of  this  kind  are  also  caused  by  obstructive  diseases  of 
the  lungs,  without  disease  of  the  heart  being  present. 

At  times  a  murmur  is  heard  which  is  not  dependent  on  a  car- 
diac affection,  but  on  lung  changes.  We  find,  for  instance,  in 
consolidation  of  the  left  apex,  especially  if  the  lung  be  also  con- 
tracted, a  murmur,  almost  invariably  systolic,  over  the  site  of  the 
pulmonary  artery;  or  we  may  encounter  over  large  cavities  with 
thin  walls  situated  in  the  neighborhood  of  the  heart  a  systolic, 
cardio-pulmonary  murmur,  caused,  most  likely,  by  the  agitation  of 
the  air  in  the  cavity,  the  heart  being  quite  sound. 

These,  then,  are  the  causes  which  impair  the  value  of  the  cardiac 
blowing  sound  as  a  sign  of  a  valvular  lesion.  Yet  they  do  not 
happen  often  enough  to  prevent  us  from  regarding  a  murmur  as 
eminently  indicative  of  an  organic  affection  of  the  valves. 

Let  us  suppose  that  we  are  convinced  that  the  murmur  is  due 
to  a  structural  lesion.  Can  we  say  what  its  precise  nature  is? 
Can  we  accurately  foretell  that  the  valve  is  merely  roughened,  or 
that  it  has  undergone  calcareous  transformation,  or  that  it  has 
been  bound  down,  or  that  it  is  lacerated,  or  that  vegetations 
spring  from  it,  or  that  its  muscular  attachments  are  sound  or 
unsound?  No,  assuredly  not.  The  most  we  can  do  is  to  judge 
whether  the  orifices  through  which  the  current  flows  be  narrowed, 
or  whether,  by  the  valves  not  closing,  they  permit  of  regurgita- 
tion ;  and  to  distinguish  even  this  we  have  to  take  into  account 
more  the  time  of  the  occurrence  of  the  sound  than  its  particular 
character  or  pitch.  Indeed,  all  distinctions  based  entirely  on 
either  of  these  are  not  borne  out  by  clinical  experience.  Valves 
incompetent  to  close  the  openings  at  which  they  are  seated  may 
permit  a  murmur  to  be  generated  of  any  character  and  of  any 
pitch.  It  is  true  that  a  harsh  murmur,  like  that  of  a  saw  or  of  a 
rasp,  is  for  the  most  part  occasioned  by  a  contracted  orifice  with 
rigid  valves ;  but  many  contracted  orifices  with  rigid  valves  exist 
without  producing  such  a  rough  noise. 


400  MEDICAL    DIAGNOSIS. 

A  cardiac  sound  which  is  rare,  but  which,  when  present,  is 
most  generally  associated  with  a  narrowed  orifice,  is  a  distinct 
musical  tone  heard  at  the  mitral  or  aortic  valves.  It  resembles 
the  cooing  of  a  pigeon  ;  or  the  auscultator  listens  and  listens 
again,  and  directs  the  patient  again  and  again  to  suspend  the 
respiration,  before  he  becomes  convinced  that  the  sound  is  not  a 
sibilant  rale  in  the  lung.  It  is  sometimes  perceived  merely  at  the 
end  of  an  ordinary  bellows  murmur,  and  disappears  and  reappears 
from  time  to  time.  Where  this  rare  sound  is  met  with,  the  valves 
after  death  are  commonly  found  to  be  rigid  and  unyielding.  Yet 
this  is  not  always  the  case.  Sometimes  the  musical  note  is  pro- 
duced by  the  vibrations  of  clots  which  impede  the  rush  of  blood 
through  the  apertures  of  the  heart,  or  by  the  loose  edge  of  a 
valve  flapping  to  and  fro  in  the  current.  Occasionally,  too,  we 
hit  upon  it  in  chlorosis;  but,  in  truth,  only  very  occasionally, 
and  never  unless  it  be  then  equally  or  more  marked  in  the  arterial 
system.  We  have  the  authority  of  Stokes  for  the  observation 
that  it  may  be  suddenly  developed  and  precede  the  signs  of 
structural  alteration  of  the  heart. 

It  has  been  already  stated  that,  on  the  whole,  we  judge  best  of 
the  state  of  the  orifices  and  of  the  valves  by  ascertaining  the 
time  at  which  the  bellows  sound  occurs.  To  do  this  it  is,  how- 
ever, necessary  to  know  in  what  condition  the  orifices  are  during 
the  movements  of  the  healthy  heart.  Let  us  briefly  recapitulate. 
During  the  contraction  of  the  ventricles,  the  valves  at  the  auriculo- 
ventricular  openings  are  closed,  to  prevent  regurgitation  into  the 
auricles ;  and  the  valves  of  the  aorta  and  pulmonary  artery  are 
open,  so  as  to  permit  the  blood  to  pass  along  the  arterial  trunks. 
During  the  dilatation  of  the  heart  the  reverse  takes  place :  the 
valves  at  the  origin  of  the  great  arteries  are  shut,  to  keep  the 
blood  which  has  just  been  sent  forth  from  regurgitating,  and  those 
valves  the  function  of  which  is  to  act  as  gates  to  the  auriculo- 
ventricular  apertures  are  swung  back,  to  allow  the  stream  to  flow 
into  the  ventricles. 

If  thus  a  murmur  occur  with  the  contraction  of  the  heart  and 
the  first  sound,  it  is  owing  to  the  blood  either  regurgitating  from 
the  ventricles  into  the  auricles,  or  meeting  with  difficulty  in 
passing  into  the  aorta  or  pulmonary  artery  ;  if  it  occur  after  the 
contraction  of  the  heart,  and  correspond  to  the  second  sound,  it  is 


DISEASES    OF    THE    HEAET. 


401 


due  to  the  blood  passing  through  a  narrowed  mitral  or  tricuspid 
orifice,  or  streaming  back  into  the  ventricles  through  incompetent 


Fig. 


Narrowing  of  the  aortic  orifice  by  vegetations  springing  from  the 
valves,  the  structure  of  which  was  indeed,  to  a  great  extent,  de- 
stroyed. The  engraving  illustrates  at  the  same  time  the  physical 
signs  of  aortic  constriction. 


aortic  or  pulmonary  valves.  But  can  we  distinguish  at  which 
valve  the  mischief  lies?  Generally  we  can.  By  attending  to  the 
site  of  greatest  intensity  of  the  murmur,  we  become  aware  of  the 
seat  of  its  production,  provided  it  be  borne  in  mind  what  are  the 
points  at  which  to  listen  to  the  different  valves.  It  is,  however, 
also  necessary  to  recollect  that,  as  the  whole  heart  is  somewhat 
lowered,  these  points  are  rather  below  what  they  are  in  a  natural 
state  of  things. 

26 


402 


MEDICAL    DIAGNOSIS. 


Now,  we  cannot  always  say  whether  more  than  one  valve  is 
affected.     A  blowing  sound  in  the  heart,  no  matter  where  gen- 


Fig.  36. 


Insufficient  mitral  valves  permitting  regurgitation  of  the  blood.  The  position  and 
time  of  occurrence  of  the  most  significant  sign  of  the  affection  are  indicated  in  the 
engraving. 

erated,  is  usually  transmitted  all  over  the  organ.  If  it  mask  the 
natural  sounds  at  other  valves,  it  is  very  difficult,  nay,  it  is  often 
impossible,  to  tell  positively  how  many  of  the  valves  are  injured, 
unless  several  spots  be  detected  at  which  the  murmur  is  intense 
and  yet  not  alike  in  character. 

Thus  the  blowing  sound  is  the  most  conspicuous  and  most  con- 
stant sign  of  a  valvular  lesion.  The  other  signs  and  symptoms 
vary  in  individual  cases.  Where  the  valves  are  but  slightly 
affected,  let  us  say  slightly  roughened,  as  they  sometimes  are  after 
an  attack  of  rheumatic  endocarditis,  the  heart  does  not  undergo 
any  decided  change  in  size ;  the  circulation  is  carried  on  regularly; 
and,  in  spite  of  the  abnormal  sound  in  the  heart,  the  patient's 
health  remains  unimpaired,  or  it  is  only  occasionally  that  he  suf- 
fers from  palpitations.  An  alteration  of  the  valves  of  the  heart 
of  any  extent   produces,  however,  an    alteration   either   in  the 


DISEASES    OP    THE    HEART.  403 

capacity  of  its  cavities  or  in  the  thickness  of  its  walls,  and  the 
symptoms  of  dilatation  or  hypertrophy  make  their  appearance 
along  with  the  physical  signs  of  extended  percussion  dulness  and 
feeble  or  heaving  impulse.  Ordinarily  it  is  the  latter  we  meet 
with,  because  the  valves  of  the  left  side  are  so  very  much  more 
frequently  diseased,  and  their  derangements  lead  to  hypertrophy 
rather  than  to  dilatation.  Affections  of  the  tricuspid  valves  are 
usually  connected  with  dilatation  of  the  organ;  hence  dropsy, 
venous  turgescence,  and  albuminous  urine  are  in  them  more 
especially  observed ;  and  Blakiston  has  taught  us  their  frequent 
association  with  engorgement  of  the  vessels  of  the  brain,  and  how 
this  becomes  the  predisposing  cause  of  cerebral  apoplexy  when  in 
connection  with  cardiac  disease.  We  also  find  in  them,  or  rather 
in  tricuspid  insufficiency,  what  Mahot  has  more  particularly  called 
attention  to, — a  pulsation  of  the  liver  corresponding  to  each  sys- 
tole of  the  heart,  perceived  by  gently  depressing  the  abdominal 
parietes  with  the  hand  on  the  epigastrium. 

All  valvular  lesions  may  be  combined  with  pain  in  the  prsecor- 
dia,  palpitations,  restlessness,  and  disturbed  dreams.  And  accord- 
ing as  the  deranged  circulation  through  the  heart  interferes  with 
the  circulation  in  other  parts,  special  symptoms  show  themselves 
prominently.  Thus,  we  find  those  who  labor  under  a  mitral  dis- 
ease suffering  most  from  cough,  from  dyspnoea,  and  from  attacks 
of  cardiac  asthma,  since  it  is  the  lung  which  has  to  bear  the  brunt 
of  the  embarrassed  flow  of  the  blood.  If  we  examine  this  organ 
closely,  the  physical  sounds  afford  direct  proof  of  its  disordered 
condition.  Here  and  there  are  heard  plentiful  moist  sounds  from 
fluid  which  has  leaked  into  the  air-tubes ;  here  and  there  the  re- 
spiratory murmur  is  roughened,  and  percussion  elicits  impaired 
clearness.  This  loss  of  the  natural  resonance  is  at  times  very 
manifest  at  the  upper  part  of  the  lung,  and  I  have  known  it  to 
lead  to  the  suspicion  of  tubercular  deposit  in  cases  in  which  the 
autopsy  showed  the  pulmonary  tissue  to  be  healthy,  though  in  a 
state  of  extreme  congestion.  Respiratory  percussion  renders  the 
sound  again  clear. 

When  the  aortic  valves  permit  of  regurgitation,  this  gives  rise 
to  effects  which  are  perceptible  along  the  track  of  the  arteries. 
These  all  look  superficial,  and  beat  with  apparent  violence,  from 
the  force  with  which  the  thickened  left  ventricle  is  driving;  the 


404 


MEDICAL    DIAGNOSIS. 


blood  through  the  tubes.  Yet,  when  the  finger  is  applied  to  the 
artery  at  the  wrist,  the  strength  of  the  beat  is  not  so  great  as  was 
expected.  A  short,  abrupt,  jerking  impulse  is  indeed  communi- 
cated to  the  finger;  but  then  the  artery  immediately  recedes, 
proving  that  it  was  only  imperfectly  filled.  This  pulse  is  the 
only  one  which  gives  us  any  real  information  as  to  the  state  of  the 
orifices  of  the  heart ;  otherwise  the  pulse  does  not  afford  any  very 
trustworthy  indications.  In  general  terms,  it  may  be  stated  to  be 
small  and  rather  tense  when  the  openings  are  narrowed.  Still, 
no  stress  can  be  laid  on  this  in  a  diagnostic  point  of  view.  The 
want  of  correspondence  between  its  strength  and  the  force  with 
which  the  heart  is  acting  is  often  amazing. 

More  information  than  by  merely  feeling  the  pulse  can  be  ob- 
tained by  studying  it  with  the  sphygmograph.  But  even  with 
this,  as  thus  far  developed,  we  gather  in  valvular  diseases  rather 
corroborative  evidence  than  knowledge  which  is  not  attainable  by 
other  means  of  diagnosis.  Perhaps,  with  further  research,  the  in- 
strument may  be  made  available  to  inform  us  with  certainty  of  the 
degree  of  the  valvular  imperfection;  and  this  would  be  a  great 

Fig.  37. 


Sphygmograin  taken  from  a  patient  with  aortic  insufficiency.  The  line  of 
ascent  does  not  terminate  in  as  sharp  a  point,  nor  is  the  descent  as  sudden,  as 
we  sometimes  find  it. 


Fig.  38. 


Sphygmogram  taken  from  a  patient  presenting  the  signs  of  mitral  regurgitation. 


step  in  advance.  As  regards  the  most  distinctive  graphical  signs, 
we  obtain  them  in  aortic  regurgitation, — a  vertical  line  of  ascent 
of  great  amplitude,  a  pointed  summit,  and  a  sudden  descent,  with 
comparatively  little  dicrotism.  If  there  be  also  marked  aortic  ob- 
struction, the  line  of  ascent  is  oblique,  or  rather  the  first  part  is 
vertical, and  following  the  sharp  point  is  a  gradual  curve-like  rise; 
if  senile  changes  in  the  artery  complicate  the  aortic  insufficiency, 


DISEASES    OP    THE    HEART. 


405 


the  sharp-pointed  process  terminating  the  line  of  ascent  passes  into 
a  more  or  less  horizontal  plateau.  In  mitral  regurgitation  the 
pulse-tracing  is  usually  very  irregular  ;  the  line  of  ascent  is  short 
and  unequal,  and  the  line  of  descent  disposed  to  be  oblique  and  to 
present  marked  dicrotism.  In  mitral  constriction,  it  is  claimed 
by  Mahomed*  that  the  up-stroke  is  vertical,  and  that  there  is, 
especially  after  giving  digitalis,  a  secondary  contraction  of  the  ven- 
tricle seen  in  the  dicrotic  wave,  which  is  very  characteristic. 

But,  instead  of  entering  into  a  detailed  description  of  the  pulse, 
however  studied,  or  of  any  separate  symptoms  of  valvular  dis- 
ease, let  us  group  them  together  with  the  physical  signs,  according 
to  the  combination  in  which  we  are  wont  to  meet  them  : 


Table  of  Valvular  Diseases. 


Seat  of  Murmlr. 

Murmur  most  in- 
tense at  or  near 
apex  of  heart. 


Seat  of  Dis- 
ease. 

Mitral  orifice. 


Murmur  most  in- 
tense at  or  near 
the  middle  of 
the  sternum,  or 
heard  with  equal 
distinctness  close 
to  the  sternum  in 
the  second  inter- 
space on  the  right 
side,  and  thence 
propagated  into 
the  arterial  sys- 
tem. 


Aortic  orifice. 


Character  of 
Disease. 

With  impulse, 
means  insuf- 
ficiency of 
valves,  permit- 
ting of  regurgi- 
tation; after 
impulse,  and 
running  into 
o  r  correspond- 
ing to  the  sec- 
ond sound,  or, 
more  accurately 
speaking,  gen- 
erally preceding 
the  first  sound, 
means  narrow- 
ing of  the  ori- 
fice. 


With  impulse, 
means  narrow- 
ing, or  obstruc- 
tion ;  with  dias- 
tole, and  taking 
the  place  of  the 
second  sound, 
means  regurgi- 
tation. 


Correlative  Physical  Signs  and  Symp- 
toms. 

In  mitral  disease  the  heart  very  com- 
monly undergoes  dilated  hypertrophy, 
especially  the  right  ventricle.  The  sec- 
ond sound  of  the  pulmonary  artery, 
heard  in  the  second  left  interspace, 
is  sharp,  accentuated.  The  cardiac 
murmur  is  most  often  distinctly  per- 
ceived posteriorly  on  the  left  side,  near 
the  angle  of  the  scapula.  Dyspnoea 
and  dropsy  are  prominent  symptoms, 
especially  dyspncea.  Cough  is  not  un- 
usual, and  the  pulse  is  not  unfrequently 
found  to  be  feeble  and  irregular.  In 
some  forms  of  mitral  obstruction,  where 
the  curtains  are  not  too  rigid,  the  mur- 
mur is  always  rough.  This  is  the  case 
usually  with  the  presystolic  murmur, 
which  is  pre-eminently  regarded  as  the 
sign  of  mitral  constriction.  But  in  this 
affection  all  murmur  may  he  absent, 
either  temporarily  or  permanently. 

Hypertrophy  of  left  ventricle.  All  the 
cardiac  sounds  may  be  normal,  except 
at  the  aortic  valve,  although  they  are 
often  somewhat  obscured  by  the  mur- 
mur. This  is  distinct  in  the  carotids 
and  is  sometimes  as  well  heard  at  the 
ensiform  cartilage  as  over  the  sternum, 
and  on  a  line  with  the  third  intercostal 
space, — a  fact  necessary  to  be  aware  of, 
so  as  to  avoid  confounding  the  aortic 
lesion  with  one  of  the  tricuspid  valve. 
"When  the  orifice  is  constricted,  a  pur- 
ring thrill  is    frequently   observed    to 


*  Medical  Times  and  Gazette,  May,  1872. 


406 


MEDICAL    DIAGNOSIS. 


Table  of  Valvular  Diseases — (Continued). 


Seat  of  Mvrmvr. 


Murmur  most  in- 
tense at  or  very 
near  to  the  ensi- 
form  cartilage, 
and  over  the 
lower  part  of 
the  right  ventri- 
cle. 


Murmur  most  in- 
tense at  third  left 
costal  cartilage 
near  the  ster- 
num, or  even 
somewhat  lower, 
or  in  second  in- 
tercostal space  to 
left  of  sternum. 


Beat  <>f  Dis- 
ease. 


Character  of 
Disease. 


Correlative  Physical  Signs  and  Symp- 
toms. 


attend  each  beat  of  the  heart.  The 
symptoms  are  often  remarkably  latent. 
There  is  very  commonly  neither  dropsy 
nor  dyspnoea.  The  pulse  is,  in  constric- 
tion, not  materially  affected ;  in  regur- 
gitation it  is  abrupt  and  jerking,  and 
all  the  superficial  arteries  pulsate  dis- 
tinctly. It  is  not  unusual  to  find  a 
double  blowing  sound  attending  aortic 
regurgitation,  probably  from  slight  co- 
existing obstruction  of  the  orifice. 
Tricuspid  ori-  With  impulse,  re-  Tricuspid  regurgitation  (for  of  tricuspid 
fice.  gurgitation;        narrowing  our  knowledge  is  little  else 

with  diastole,  than  theoretical)  exists  very  usually  in 
and  taking  combination  with  dilatation  of  the  right 
therefore  the  ventricle,  and  therefore  with  the  symp- 
place  of  the  sec-  toms  of  this  condition  :  with  venous  con- 
ond  sound,  or  gestions,  with  dropsies,  with  difficulty 
preceding  the  in  breathing.  On  account  of  the  open 
first,  narrow-  state  of  the  orifice,  the  cervical  veins 
ing.  may  pulsate  during  the  movements  of 

the  heart;  and  in  all  cases  they  are  dis- 
tended. The  pulsatile  motion  in  the 
neck  becomes  especially  visible  when 
the  breath  is  held  in  expiration.  The 
cardiac  murmur  is  ordinarily  soft,  of 
low  pitch,  is  not  transmitted  into  the 
arteries,  and  is  not  heard  above  the  level 
of  the  third  rib.  In  some  cases  it  is  so 
feeble  as  to  be  with  difficulty  discerned. 
Pulmonary  With  impulse,  is  We  have  very  little  actual  knowledge, 
orifice.  narrowing;        derived    from    clinical    observation,    of 

taking  the  place  diseases  of  the  pulmonary  valves  ;  of  all 
of  the  second  the  valves  the  ones  most  rarely  affected. 
sound,  regnrgi-  Nor  does  a  murmur  in  the  situation  in- 
lation.  dicated,   and   hardly   audible  over  the 

left  apex  or  along  the  sternum,  or  in 
the  course  of  the  great  vessels,  having 
therefore  the  characteristics  of  a  pul- 
monic murmur,  warrant  a  diagnosis  of 
disease  of  the  valves :  for  it  may  be  due 
to  anaemia  ;  be  caused  by  deposits  at  the 
upper  part  of  the  left  lung ;  or  be  ob- 
served immediately  after  or  during  the 
continuance  of  hemorrhage  from  the 
lungs.  But  these  remarks  scarcely  hold 
good  with  reference  to  a  diastolic  mur- 
mur, and  not  at  all  as  regards  a  double 
murmur.  If  this  be  present,  and  signs 
of  dilated  hypertrophy  exist,  we  are 
justified  in  concluding  the  disease  to  be 
a  lesion  of  the  pulmonary  valves,  or  at 
the  origin  of  the  artery.  But  as  regards 
the  association  with  signs  of  hypertrophy 
especially,  we  must  bear  in  mind  that  in 
rare  instances  of  mitral  disease,  espe- 
cially regurgitation,  the  murmur  is 
loudest  at  the  pulmonary  area. 


DISEASES    OF    THE    HEART.  407 

In  this  manner  are  the  symptoms  and  signs  of  valvular  affec- 
tions associated.  I  do  not  pretend  to  say  that  this  is  exactly  the 
combination  and  precisely  the  way  in  which  they  happen  in  every 
instance.  There  are  too  many  circumstances  which  modify  them  ; 
disorders  of  several  valves  are  too  constantly  conjoined :  at  the 
same  orifice  both  narrowing  and  a  state  permitting  of  regurgita- 
tion are  too  often  found  to  coexist, — to  permit  any  tabular  repre- 
sentation to  express  either  all  the  symptoms  or  all  the  signs  which 
may  occur  in  individual  cases.  Apart  from  this  difficulty,  there 
is  another :  even  where  the  affection  of  a  second  valve  has  been 
correctly  fixed  upon,  the  irregularity  of  the  heart's  action  may 
be  such  that  it  is  impossible  to  say  whether  the  blowing  sound 
heard  be  systolic  or  diastolic;  whether,  therefore,  the  orifice  be 
narrowed  or  the  valves  insufficient.  But  this  is  not  a  matter  of  so 
much  consequence ;  the  matter  of  consequence  is,  to  determine  that 
a  disease  of  the  valves  is  present. 

Presuming  that  we  have  been  enabled  to  fix,  and  to  fix  accu- 
rately, the  state  of  each  aperture,  there  is  a  point  where  all  our 
skill  invariably  comes  to  a  stand-still.  We  cannot  tell  how  long 
it  is  possible  for  life  to  continue,  or  under  what  circumstances 
death  will  happen.  It  may  take  place  suddenly  and  most  unex- 
pectedly in  cases  in  which  the  amount  of  disease  in  the  heart  is 
not  found  to  be  great ;  and,  on  the  other  hand,  life,  and  even  a 
tolerable  degree  of  health,  may  be  maintained  with  valves  so  rigid 
and  unyielding  that  the  point  of  the  knife  can,  at  the  autopsy, 
hardly  be  forced  through  them.  In  mitral  disease,  the  patient 
is  liable  to  be  worn  out  by  the  dropsy  and  by  the  increasing  dif- 
ficulty of  breathing ;  and  so,  too,  in  that  still  more  serious  lesion, 
— tricuspid  regurgitation.  In  affections  of  the  aortic  valves  the 
patient  suffers  less,  but  he  is  more  liable  to  sudden  death. 

Before  dismissing  these  valvular  affections,  there  are  a  few  other 
matters  which  claim  consideration,  though  the  limits  set  to  this 
work  will  prevent  their  full  discussion.  The  blowing  sound  has 
been  insisted  upon  as  the  diagnostic  sign  of  a  valvular  lesion,  and 
to  insist  upon  this  is  to  do  no  more  than  universal  experience 
warrants.  But  there  are  undoubtedly  instances  in  which  no 
murmur  reaches  the  ear  to  show  that  the  valves  are  damaged. 

I  shall  cite  two  examples.  A  man,  thirty-five  years  of  age, 
came  under  my  care,  complaining  of  palpitation  of  the  heart,  of 


408  MEDICAL    DIAGNOSIS. 

occasional  attacks  of  bronchitis,  and  of  shortness  of  breath.  His 
health  was  otherwise  good.  A  physical  examination  of  the  chest 
showed  the  action  of  the  heart  to  be  extremely  disturbed :  the 
impulse  was  strong,  and  the  extent  of  dullness  in  the  precordial 
region  increased.  A  blowing  sound  was  heard  near  the  apex,  but, 
owing  to  the  great  irregularity  of  the  movements  of  the  heart,  it 
was  impossible  to  say  whether  it  corresponded  in  time  to  the  con- 
traction or  to  the  relaxation  of  the  organ.  The  pulse  was  small, 
frequent,  and  intermittent.  The  patient  continued  in  this  state 
for  seven  months,  the  beat  of  the  heart  becoming  more  and  more 
tumultuous;  but  the  murmur  gradually  disappeared.  A  peculiar 
clacking  sound  took  its  place,  which  was  most  distinct  near  the 
apex,  and  was  faintly  transmitted  to  other  portions  of  the  heart. 
It  occurred  with  but  one  sound  of  the  heart, — with  which  could 
not  be  determined.  For  some  time  before  his  death  he  had  con- 
siderable cough,  with  a  frothy  expectoration  and  great  difficulty  in 
breathing.  His  face  and  hands  had  begun  to  swell.  The  imme- 
diate cause  of  death  was  pulmonary  apoplexy.  The  heart  was 
found  in  a  state  of  dilated  hypertrophy,  and  the  mitral  valves 
had  been  converted  into  a  calcareous  mass,  which  had  left  but  an 
extremely  narrow  chink  for  the  blood  to  pass  through. 

The  next  case  presents,  in  several  respects,  a  striking  similarity. 
A  gentleman,  about  fifty  years  of  age,  who  had  led  a  gay  and 
somewhat  dissipated  life,  noticed  that  he  experienced  difficulty  in 
breathing  on  the  slightest  exertion.  He  complained  also  much 
of  loss  of  appetite  and  of  distention  of  the  stomach.  I  could  not 
find  any  cause  beyond  flatulence  to  account  for  this ;  the  abdomen 
yielded  all  over  an  extremely  tympanitic  sound.  But  to  the 
dyspnoea,  an  inquiry  into  the  state  of  the  heart  furnished  a  clue. 
The  size  of  the  organ  was  evidently  augmented,  and  its  rhythm 
very  irregular.  The  impulse  was  strong;  but  the  sounds  were 
normal,  except  near  the  apex,  where,  taking  the  place  of  one, 
was  heard  a  dull  but  very  marked  clack.  When  the  hand  was 
applied  over  this  point,  it  felt  a  vibration  of  very  much  the  same 
character  as  that  which  the  ear  could  hear,  and,  like  this,  it  was 
limited,  or  certainly  only  distinctly  perceptible,  at  or  near  the 
apex  of  the  organ.  The  diagnosis  of  disease  of  the  mitral  valves 
was  made,  and  it  proved  to  be  correct.  The  dyspnoea  became 
greater  and  greater;  the  feet,  and   subsequently  the  abdomen, 


DISEASES    OF    THE    HEART.  409 

were  distended  with  fluid ;  and  the  patient  died  with  all  the 
symptoms  of  an  unmistakable  valvular  lesion. 

My  note-book  would  furnish  me  with  many  more  such  cases ; 
but  these  two  present  the  main  features  of  all.  All  the  instances 
of  valvular  disease  I  have  met  with,  unaccompanied  by  blowing 
sounds,  have  been  instances  of  disease  at  the  mitral  orifice,  and  of 
extreme  narrowing  of  that  orifice.  They  were  all  attended  with 
excessive  irregularity  of  the  action  of  the  heart,  and  with  hyper- 
trophy. They  all  produced  difficulty  of  breathing.  They  all 
presented  this  peculiar  clacking  sound  most  marked  near  the  apex. 
In  some,  another  sound,  more  like  that  heard  in  health,  followed 
it ;  in  others,  not.  In  some,  the  blowing  sound  gradually  disap- 
peared ;  in  others,  none  was  perceived  when  first  examined;  and 
in  others,  again,  it  could  be  caught  occasionally,  as  a  very  short 
whiff,  along  with  the  clacking  sound.  In  all  the  impulse  was 
strong  and  very  variable  in  its  rhythm,  and  a  peculiar  movement 
was  felt  near  the  seat  of  the  apex, — not  the  purring  tremor  which 
so  commonly  accompanies  the  movements  of  a  heart  the  valves  of 
which  are  damaged,  but  a  more  localized  vibration,  similar,  as  far 
as  such  similarity  can  exist,  to  the  sound  the  ear  hears. 

These  cases  are  probably  of  the  same  nature  as  those  that  are 
every  now  and  then  reported  as  valvular  lesions  in  which  the 
sounds  of  the  heart  were  normal.  I  cannot  think  that  with  a 
disease  of  the  valves  they  ever  are  so.  There  may  be  no  blowing 
sounds  present,  but  the  sounds  of  the  valve  affected  must  be  dif- 
ferent from  what  they  are  in  health ;  and  it  may  again,  in  all 
truth,  be  said  that  to  hear  the  natural  sounds  of  the  heart  well 
defined  is  to  be  able  to  exclude  a  valvular  disease. 

The  other  subject  to  which  we  may,  in  conclusion,  advert,  is 
the  possibility  of  valves  having  been  insufficient  to  perform  their 
functions  during  life,  and  yet  no  signs  of  their  incompetence 
being  detected  after  death,  at  least  none  being  indicated  by  any 
structural  change  in  the  valves.  That  such  cases  occur,  is  attested 
by  more  than  one  observer.  They  have  generally  been  found 
to  be  connected  with  dilatation  of  the  ventricles  of  the  heart, 
and  are  perhaps  due,  as  suggested  by  Dr.  Bristowe,*  to  a  ven- 

*  British  and  Foreign  Med.-Chir.  Eeview,  July,  1861.  See  also  cases  by- 
Hare,  Transactions  of  London  Pathological  Society,  vol.  ii.,  and  by  Cuming, 
Dublin  Quarterly  Journal,  May,  1868. 


410  MEDICAL    DIAGNOSIS. 

tricle  becoming  dilated  without  a  corresponding  elongation  of  the 
musculi  papiliares  and  chordae  tendinese.  Of  course  this  explana- 
tion holds  good  with  reference  only  to  regurgitation  through  the 
auriculo-ventricular  apertures ;  but  it  is  to  this  condition  that  the 
instances  recorded  refer.  Yet  in  explaining  them  we  must  not 
overlook  those  blowing  sounds  produced  by  mere  abnormal  action 
of  the  textures  of  the  heart,  to  which  we  have  elsewhere  alluded, 
and  the  existence  of  which  no  one  can  call  in  question  * 

Valvular  disease  may  be  at  times  suddenly  developed,  from 
rupture  of  a  valvulet  or  of  a  papillary  muscle  by  a  severe  strain. 
I  have  known  such  cases  to  happen  where  there  was  nothing  in 
the  history  to  lead  to  the  belief  of  previous  disease,  though  often 
there  is  some  preceding  disorganization,  such  as  a  granular  or  a 
fatty  change.  One  of  the  most  striking  diagnostic  features  is  the 
quickly  originating  organic  murmur  attending  the  signs  of  dis- 
ordered circulation  and  cardiac  distress ;  another,  the  occurrence 
of  pain  in  the  region  of  the  heart. 

Let  me  also  briefly  here  allude  to  another  subject, — whether  the 
valvular  affection  shows  any  signs  by  which  we  can  recognize  it 
before  the  development  of  a  murmur.  We  cannot  do  so  with  any 
certainty ;  although  marked  alteration,  such  as  dulness  of  sound 
confined  or  most  obvious  at  a  particular  valve ;  the  signs  of  pre- 
ceding or  of  growing  hypertrophy ;  and,  where  the  aortic  valves 
are  concerned,  a  distinct  accentuation  of  the  second  sound,  while 
the  first  has  become  dull  and  changed, — might  make  us  suspect 
what  is  about  to  happen. 

Displacements  of  the  Heart, 

The  heart  is  a  very  movable  organ.  This  is  proved  by  the 
ease  with  which  it  is  displaced,  and  with  which  it  returns  to  its 
normal  position.  Its  apex  is  tilted  upward  by  an  enlarged  liver, 
by  an  abdominal  tumor,  or  by  a  pericardial  effusion.  It  gravi- 
tates toward  the  median  line  when  the  walls  of  the  heart  have 
increased  in  weight  and  firmness.  But  these  changes  are  hardly 
of  a  nature  to  attract  as  much  attention  as  finding  a  heart  beating 
on  the  right  side  of  the  sternum. 

Now,  it  is  not  very  uncommon  to  meet  with  it  there;  and  the 
question  immediately  arises,  What  does  this  strange  alteration  in 
its  situation  signify,  and  how  is  it  brought  about?     It  is  usually 


THORACIC    ANEURISM.  411 

produced  by  pressure  exercised  on  the  heart  by  accumulations  of 
fluid  or  of  air  in  the  left  pleural  cavity,  and  therefore  denotes, 
as  a  rule,  a  pleuritic  effusion  or  a  pneumothorax  of  the  left  side, 
and  is  accompanied  by  distention  of  that  side.  In  rarer  instances, 
the  heart  is  pushed  across  by  a  highly  distended  emphysematous 
lung;  in  still  rarer  instances,  it  is  drawn  over  to  the  right  side 
by  a  shrinking  of  the  lung,  attended  with  dilatation  of  the  bron- 
chial tubes,  the  so-called  pulmonary  cirrhosis.  It  is  sometimes 
found  on  the  right  side,  because  it  had  been  forced  there  by  a 
pleuritic  effusion  and  had  formed  adhesions,  so  that  when  the  fluid 
was  absorbed  it  was  unable  to  return  to  its  natural  place.  In  this 
case  the  left  side  will  be  markedly  retracted,  and  not  the  right,  as 
it  is  if  cirrhosis  of  the  right  lung  be  the  cause  of  the  abnormal 
position  of  the  heart. 

The  displacement  may  further  have  been  brought  about  by  a 
cancerous  or  an  aneurismal  tumor,  or  by  any  of  the  abdominal 
viscera  having  slipped  into  the  chest  through  a  hernial  opening 
in  the  diaphragm;  or  it  may  be  congenital.  But  these  all  are 
causes  which  seldom  exist.  Practically  speaking,  transpositions 
of  the  heart  are  met  with  in  connection  with  diseases  of  the  lungs. 
We  shall  merely  add  that  a  congenital  displacement  cannot  be 
diagnosticated  unless  all  other  causes  capable  of  producing  a  dis- 
placement have  been  proved  to  be  absent ;  and  that  a  dislocated 
heart  is  able  to  perform  all  its  functions.  It  may  even  be  at- 
tacked by  acute  disease;  the  recognition  of  which,*  under  such 
circumstances,  belongs  to  the  triumphs  of  physical  diagnosis. 


SECTION   III. 


THORACIC   ANEURISM. 


The  heart  is  not  the  only  part  of  the  circulatory  system  within 
the  chest  which  is  liable  to  become  diseased.  The  great  vessels 
which  spring  from  it  are  subject  to  the  same  morbid  conditions 

*  As  by  Stokes.     See  Diseases  of  the  Heart,  p.  463. 


412  MEDICAL    DIAGNOSIS. 

as  the  vessels  of  any  other  portion  of  the  body.  Especially  do  we 
find  this  to  be  the  case  with  the  aorta,  the  coats  of  which  become 
inflamed  or  are  frequently  roughened  by  calcareous  or  atheroma- 
tous deposits.  Inflammation  of  the  external  coat,  which  more 
often  aflfects  the  thoracic  aorta  than  any  other  large  vessel  in 
the  body,  may  arise  in  chronic  inflammation  of  the  inner  coat,  or 
follow  inflammation  of  surrounding  connective  tissue.  It  may 
lead  to  suppuration,  and,  the  pus  finding  its  way  into  the  calibre 
of  the  vessel,  pyaemia  and  metastatic  abscesses  are  caused.  But  it 
is  not  possible  to  make  a  diagnosis  of  the  condition :  if  correct,  it 
is  but  a  good  guess.  Chronic  inflammation  of  the  inner  coat,  with 
the  attending  atheromatous  changes,  is  very  common.  These  alter- 
ations, happening  in  internal  arteries,  too,  are  beyond  the  accurate 
discernment  of  the  physician.  He  may  infer  that  they  exist,  if  a 
distinct  systolic  blowing  sound  be  heard  in  the  track  of  the  aorta 
or  its  branches,  in  a  person  who  is  not  anaemic,  who  is  past  middle 
life, — and  therefore  at  an  age  at  which  these  kinds  of  alteration  of 
tissues  happen, — and  in  whom  no  cardiac  murmurs,  or  only  faint 
cardiac  murmurs,  are  perceived.  But  it  is  chiefly  by  the  general 
circumstances  of  the  case,  and  the  rigid  superficial  arteries,  and 
the  gradual  development  of  cardiac  enlargement  from  the  resist- 
ance to  the  circulation,  that  a  conclusion  as  to  the  meaning  of  the 
physical  signs  is  arrived  at;  and  really  it  is  not  until  after  death 
that  the  precise  nature  or  extent  of  the  structural  lesions  is  learned. 
They  are,  thus,  interesting  chiefly  to  the  pathologist;  yet  they  are 
important,  because  these  changes  in  the  coats  of  the  arteries  are 
often  the  first  step  toward  their  laceration  or  a  dilatation  of  the 
vessels;  in  other  words,  toward  the  establishment  of  an  aneurism. 
Now,  an  aneurism  of  the  aorta,  whether  caused  by  a  disease  of 
the  coats  of  the  artery  or  not,  whether  true  or  false,  may  affect 
any  part  of  the  vessel.  Yet  it  is  chiefly  at  the  ascending  portion 
and  at  the  arch  that  it  is  met  with.  When  it  occurs  just  after  the 
artery  has  left  the  heart,  it  is  prone  to  elude  discovery.  Higher 
up,  nearer  to,  or  at  the  arch,  it  more  rarely  escapes  detection.  The 
tumor  manifests  itself  by  a  local  bulging,  varying  in  extent  and 
situation  according  to  the  extent  and  situation  of  the  aneurism. 
A  single  rib  alone  may  be  raised,  or  nothing  but  a  fulness  may  be 
observed.  But  some  prominent  spot  is  generally  detected,  and 
when  this  is  percussed  it  is  more  resistant,  and  returns  a  duller 


THORACIC    ANEURISM.  413 

sound,  than  when  there  is  nothing  wrong  underneath.  Yet  neither 
the  bulging  nor  the  dulness  on  percussion  is  of  as  much  significance 
as  finding  a  distinct  pulsation  remote  from  the  beat  of  the  heart. 
Every  time  the  latter  is  perceived,  an  impulse  is  communicated 
to  the  finger  at  the  point  in  the  chest-walls  which  appears  to  pro- 
ject ;  that  is,  usually  on  the  right  side  of  the  sternum  in  the  second 
intercostal  space,  or  in  the  same  interspace  on  the  left  side,  or 
immediately  under  the  top  of  the  bone.  Occasionally  the  beat  is 
double,  at  times  so  violent  as  to  shake  the  head  of  the  listener, 
and  almost  always,  unless  the  aneurism  be  filled  with  solid  clots, 
stronger  than  the  beat  of  the  heart. 

The  impulse  may  be  accompanied  by  a  distinct  thrill.  But 
this  is  not  always  present,  and,  when  present,  is  not  always  con- 
stant ;  since  it  may  disappear  and  reappear.  It  is  thus  a  serious 
mistake  to  regard  the  thrill  as  the  requisite  sign  of  an  aneurismal 
enlargement ;  yet  there  is  no  mistake  more  common,  except,  per- 
haps, one, — to  consider  that  the  motion  of  the  blood  in  the  sac 
must  necessarily  engender  a  murmur.  The  ear,  applied  over' the 
prominence,  hears  often  nothing  that  in  the  least  resembles  a  mur- 
mur, but  sounds  like  those  of  the  heart,  sometimes  two,  the  first 
weighty  and  prolonged ;  sometimes  but  one,  and  that  one  longer 
and  more  intense  than  the  corresponding  first  sound  over  the 
ventricles. 

Thus,  then,  neither  thrill  nor  murmur  is  essential  to  the  diag- 
nosis of  an  aneurism.  What  is  much  more  essential,  is  to  find 
two  points  of  pulsation  in  the  chest, — two  hearts  apparently,  each 
with  its  own  distinct  beat,  its  own  distinct  sounds. 

An  aneurismal  tumor  in  the  chest  gives  rise  to  symptoms  which 
vary  somewhat  according  to  its  seat  and  extent.  Prominent  among 
them  stand  those  occasioned  by  pressure.  The  sac  presses  on  the 
adjacent  air-tubes,  and  shortness  of  breathing,  or  peculiar  cough 
and  signs  counterfeiting  those  of  a  chronic  laryngeal  disease,  are 
the  result;  or  it  presses  on  the  oesophagus,  and  the  patient  suffers 
from  difficulty  in  swallowing;  or  it  presses  on  the  subclavian 
artery,  and  the  pulses  at  the  two  wrists  are  noticed  to  be  strikingly 
different ;  or  on  the  carotid,  and  pain  in  the  head,  dulness  of  mind, 
occasional  giddiness,  and  flashes  of  light  before  the  eyes,  are  com- 
plained of;  or  on  the  venous  trunks,  and  the  superficial  veins  of 
the  neck  and  thorax  are  seen  to  be  engorged,  and  the  skin  be- 


414  MEDICAL    DIAGNOSIS. 

comes  very  puffy  and  swollen  ;  or  on  the  trunk  of  the  sympathetic 
nerve  or  on  its  ganglia  and  their  communications,  and  marked 
contraction,  or,  in  rare  instances,  dilatation  of  the  pupil  of  the 
eye  on  the  side  of  the  aneurismal  swelling,  is  perceived,  or  profuse 
sweating  becomes  an  annoying  complication.  All  these  signs, 
then,  denote  pressure,  and  pressure  connected  with  a  pulsating 
tumor  in  the  chest  means  an  aneurism. 

I  say  with  a  pulsating  tumor,  because  a  cancerous  or  any  other 
morbid  groivth  may  produce  exactly  the  same  signs  of  compression 
as  an  aneurismal  tumor, — the  same  stridor,  the  same  cough,  the 
same  feebleness  of  respiration  in  one  lung  from  partial  obliteration 
of  its  bronchial  tube.  But  the  solid  tumor,  large  though  it  be, 
does  not  pulsate,  or,  if  it  do,  pulsates  but  very  feebly,  and  not 
with  the  heaving  motion  of  a  distending  aneurismal  sac*  The 
tumor  renders  a  large  surface  dull  on  percussion,  and  communi- 
cates a  much  greater  feeling  of  resistance  to  the  percussing  finger. 
Yet  the  ear  listens  in  vain  over  the  prominence  for  the  weighty 
sound  with  each  beat  of  the  heart,  or  for  the  hoarse  murmur  of 
the  blood  streaming  through  the  sac.  It  is  only  where  a  solid 
growth  presses  on  the  artery  that  any  murmur  is  perceived;  and 
this  is  different  from  the  superficial  loud  sounds  or  murmurs  of 
an  aneurism.  Further,  a  tumor  is  not  confined  to  the  course  of 
the  aorta ;  it  is  more  commonly  connected  with  a  distended  state 
of  the  veins  of  the  neck  and  thorax,  and  with  oedema  of  the  arm 
and  chest ;  the  pain  it  occasions  is  often  more  continued,  and  less 
neuralgic  in  its  nature.  Moreover,  as  most  thoracic  tumors  are 
cancerous,  the  violent  constitutional  disturbance,  the  formation  of 
external  swellings,  and  the  peculiar  currant-jelly  expectoration, 
aid  us  in  arriving  at  a  correct  conclusion.  The  obvious  inequality 
of  the  pupils,  which  is  found  in  a  certain  number  of  cases  among 
the  signs  of  an  aneurism,  is  of  little  aid  in  a  differential  diagnosis, 
for  a  thoracic  cancer  has  been  noted  to  occasion  the  same.t     The 

*  This  same  absence  of  distinct  pulsation  was  the  main  point  of  dissimi- 
larity between  an  aneurism  and  an  abscess  of  the  mediastinum  some  time 
since  under  my  care,  which,  after  lasting  a  year,  and  simulating  aneurism 
most  closely  in  the  pain,  the  dulness  on  percussion,  the  difficulty  of  breathing 
and  of  swallowing,  and  the  altered  voice,  got  well  by  breaking  internally  and 
by  the  discharge,  as  expectoration,  of  large  amounts  of  purulent  matter. 

f  MacDonnell,  Montreal  Medical  Chronicle,  June,  1858;  see,  also,  the  Ee- 


THORACIC    ANEURISM.  415 

rarity  of  a  non-aneurismal  tumor  in  the  chest  is,  however,  very 
great;  and,  practically  speaking,  when  the  signs  of  an  intra- 
thoracic tumor  are  met  with  we  shall  be  generally  correct  in 
thinking  that  it  is  an  aneurism  we  have  to  treat,  even  should 
the  pulsations  not  be  very  obvious. 

Let  us  suppose  that  we  are  satisfied,  owing  to  a  marked  impulse, 
that  we  have  not  a  solid  growth  to  deal  with, — does  a  pulsation 
uniformly  denote  an  aneurism  ?  Can  we  absolutely  say,  on  ac- 
count of  the  impulse,  that  it  is  an  aneurismal  enlargement  ?  If 
there  be  also  a  swelling  and  signs  of  pressure,  we  can ;  should 
these  not  exist,  we  cannot  be  quite  so  sure.  For  a  pulsation  in 
the  chest  not  immediately  over  the  region  of  the  heart,  although 
it  is  nearly  always  indicative  of  an  aneurism,  may  be  owing  to 
other  causes. 

Where  the  aortic  valves  are  insufficient,  and  permit  of  regurgi- 
tation, there  may  be  a  pulsation  in  the  aorta ;  an  empyema  may 
pulsate ;  a  dilated  auricle  may  occasion  an  impulse  separate  from 
that  of  the  ventricles;  a  pulmonary  artery  surrounded  by  con- 
solidated lung  may  distinctly  exhibit  its  beat.  In  all  of  these  the 
signs  of  pressure  on  the  surrounding  parts  are  wanting ;  and,  on 
the  other  hand,  they  show  phenomena  which  an  aneurism  lacks. 

Insufficient  aortic  valves  are  accompanied  by  hypertrophy  of  the 
left  ventricle.  So  is  very  constantly  a  thoracic  aneurism;  but, 
instead  of  the  throbbing  at  the  upper  anterior  part  of  the  chest 
being  attended,  as  it  is  in  aneurismal  swelling,  with  a  natural 
or  an  unequal  and  diminished  beat  at  the  wrist,  there,  as  well 
as  in  the  larger  trunks  in  the  neck  and  arms,  is  perceived  that 
strong  and  peculiar  pulsation  which  is  so  characteristic  a  sign  of 
inadequate  aortic  valves.  Then,  again,  a  murmur  is  much  more 
common  in  this  organic  affection  of  the  valves  than  it  is  in  aortic 
aneurism;  and  is  usually  a  loud  double  murmur,  very  distinct  at 
the  right  base  of  the  heart,  and  associated  with  a  double  murmur 
in  the  femorals  made  evident  by  pressure  with  the  stethoscope. 
This  is  very  rare  in  aneurism  of  the  aorta;  moreover,  the  murmur 
heard  over  an  aneurismal  pulsation  is  better  marked  over  its  seat 
than  over  the  heart,  and  is  mostly  single,  systolic,  and  short, 


searches  of   Gairdner,  Clinical  Medicine,  and  of  Ogle,  Medico-Chirurgical 
Transactions,  vol.  xli. 


416  MEDICAL    DIAGNOSIS. 

hoarse,  and  of  low  pitch.  In  truth,  it  differs  in  distinctness  as 
well  as  in  quality  from  the  murmur  discerned  at  the  base  of  the 
heart,  which  may  be  transmitted  from  the  aneurism,  or  may  depend 
upon  coexisting  cardiac  disease.  While  alluding  to  the  diagnosis 
of  aortic  valve  disorder,  I  may  mention  coarctation  or  constriction 
of  the  aorta,  which  in  very  rare  cases  is  associated  with  the  valvu- 
lar affection.  It  generally  happens  just  at  or  below  the  insertion 
of  the  ductus  arteriosus,  and  furnishes  as  its  only  special  signs  a 
dilatation  of  certain  collateral  vessels  at  the  upper  part  of  the 
thorax  and  diminished  size  and  feeble,  retarded  pulsation  of  the 
femorals.  The  arteries  of  the  head  and  neck,  as  well  as  the  epi- 
gastric and  mammary  arteries,  throb,  and  there  may  be  a  marked 
thrill  at  the  upper  part  of  the  chest  near  the  sternum,  and  a 
murmur  there  louder  than  over  the  heart ;  pressure-signs  are  ab- 
sent, and  the  dilated  vessels  are  often  the  seat  of  a  purring  noise.* 

A  pulsating  empyema  is  seldom  met  with  ;  yet  a  collection  of 
fluid  in  the  cavity  of  the  chest  may  vibrate  with  the  motion  of  the 
heart,  and  throb  with  such  distinctness  as  closely  to  simulate  an 
aneurism.  To  determine  the  real  nature  of  the  pulsation  in  these 
cases,  we  must  attach  importance  to  the  situation  of  the  expanding 
mass,  which  is  not  often  that  of  an  aneurism,  and  to  the  signs 
which  point  out  that  liquid  has  accumulated  within  the  pleural 
sac.  We  also  note  the  circumstance  that  over  the  seat  of  impulse 
there  are  no  peculiarly  marked  sounds,  no  murmurs,  no  thrill ; 
moreover,  the  beat  is  not  apt  to  be  as  strong  as  that  of  the  heart. 

A  dilated  auricle,  the  walls  of  which  are  at  the  same  time 
hypertrophied,  may  give  rise  to  a  movement  separate  from  that 
of  the  beat  of  the  ventricle.  Bouillaud  cites  an  example  of  this 
nature,  in  which  a  double  motion  was  perceptible  in  the  second 
intercostal  space  of  the  left  side,  in  a  person  whose  heart  was 
extensively  hypertrophied  and  whose  mitral  valves  were  indu- 
rated. Such  cases  are  extremely  rare.  The  signs  of  an  accom- 
panying valvular  affection  and  of  enlargement  of  the  ventricles, 
and  the  probable  presence  of  dropsy,  would  serve  to  distinguish  a 
dilated  auricle  from  aneurism  of  the  arch.     And  this  is  the  only 

*  For  cases  of  coarctation  of  the  aorta,  see  Peacock,  Brit,  and  For.  Med.- 
Chir.  Kev.,  April,  1860;  Walshe,  Med.  Times  and  Gaz.,  Oct.  1857 ;  Meigs, 
Anier.  Journ.  of  Med.  Sciences,  Jan.  1869;  Lebert,  in  Virchow's  Handbuch ; 
Quincke,  in  Ziemssen's  Cyclopaedia. 


THORACIC    ANEURISM.  417 

form  of  enlargement  of  the  heart  which  is  at  all  likely  to  be 
mistaken  for  an  aneurism.  In  cases  of  hypertrophy  or  dila- 
tation as  we  ordinarily  meet  with  them,  there  is  but  one  motion 
discernible, — that  over  the  ventricles, — and  not  two  beats  at 
some  distance  from  each  other;  the  signs  of  pressure,  too,  are 
wanting. 

A  pulmonary  artery  surrounded  by  consolidated  lung-tissue  may 
cause — especially  if,  in  addition,  the  vessel  be  somewhat  widened 
— a  very  distinct  pulsation.  But  the  seat  of  the  dulness  at  or 
near  the  apex  of  the  left  lung ;  its  non-extension  over  the  median 
line ;  the  limitation  of  the  murmur  to  the  site  of  the  pulmonary 
artery,  or,  in  some  instances,  to  this  vessel  and  the  subclavian;  the 
sharply-defined  second  sound  of  the  pulmonary  artery  in  the  second 
interspace  on  the  left  side ;  the  symptoms  and  physical  signs  of 
phthisis,  the  most  common  cause  of  the  consolidation,  and  a  morbid 
condition  which  of  itself  would  appear  to  exclude  an  aneurism ;  the 
absence  of  pain  and  of  the  phenomena  caused  by  pressure, — all 
these  prove  the  murmur  and  the  pulsation  not  to  be  due  to  an 
aortic  aneurism.  Absence  of  pain  and  of  pressure-signs,  and  ac- 
centuation of  the  second  sound,  are  also  the  chief  signs  by  which 
we  distinguish  those  comparatively  rare  cases  of  murmur  in  the 
second  interspace,  close  to  the  left  of  the  sternum,  which  are  due  to 
retraction  of  the  lung  and  uncovering  of  the  heart  and  pulmonary 
artery.  The  murmur,  which  has  been  specially  studied  and  ex- 
plained by  Quincke*  and  Balfour,  f  is  systolic  and  loud,  and  mostly 
disappears  on  deep  inspiration.  The  pulsation  is  marked,  though 
not  as  strong  as  that  of  the  heart;  the  singular  murmur  is  sup- 
posed to  be  owing  to  compression  of  the  pulmonary  artery  by  the 
heart  during  the  systole.  In  many  respects  it  is  like  the  murmur 
heard  over  the  pulmonary  artery  in  certain  lung  affections,  which 
I  have  elsewhere  investigated.! 

Another  abnormal  condition  which  may  be  mistaken  for  an 
aneurism  is  a  malformation  of  the  chest,  particularly  when  pro- 
duced by  great  prominence  of  the  upper  part  of  the  sternum. 
This  error  is  more  especially  apt  to  occur  if  there  be  coexist- 
ing disturbance  of  the  heart,  whether  of  functional  or  of  organic 

*  Berlin.  Klinische  Wochenschrift,  1870. 
f  Lectures  on  Diseases  of  the  Heart,  London,  1876. 
j  Amer.  Jour,  of  Med.  Sciences,  Jan.  1859. 
•27 


418  MEDICAL    DIAGNOSIS. 

origin.  I  saw  some  time  since  a  case  where  the  beating  of  the 
arteries  of  the  neck,  accompanied  by  an  enlargement  of  the  thy- 
roid gland  and  by  cardiac  palpitation,  was  believed  to  be  an  aneu- 
rism, mainly  because  it  was  combined  with  very  decided  promi- 
nence of  the  upper  portion  of  the  sternum.  But  there  were  no 
distinctly  localized  tumefaction  and  pulsation,  no  altered  sounds, 
no  signs  of  pressure.  I  have  also  met  with  instances  in  which 
the  active  pulsation  of  the  thyroid  gland,  in  cases  both  of  ex- 
ophthalmic and  of  ordinary  goitre,  gave  rise  to  the  idea  of  an 
aneurism,  but  in  which  no  change  of  the  chest-walls  existed. 
In  such  cases  the  carotids  and  radials  beat  equally;  a  blowing 
murmur,  attended  by  a  continuous  hum,  is  heard — certainly  in 
instances  of  exophthalmic  goitre — over  the  enlarged  gland;  there 
is  nowhere  a  point  of  localized  pulsation,  and  there  are  also  no 
signs  of  pressure. 

Malposition  of  the  aorta,  due  to  rickets,  may  simulate  an  aneu- 
rism very  closely.  Balfour*  has  called  our  attention  to  such  cases, 
and  pointed  out  how  misleading  may  be  the  abnormal  pulsation 
with  the  dulness  on  percussion,  and  the  right-sided  prominence  of 
the  chest.  Moreover,  thrill,  murmurs  loudest  over  the  pulsating 
mass,  and  cardiac  hypertrophy,  may  coexist.  We  must  be  guided 
in  our  opinion  by  the  history  of  the  case ;  by  the  distortion  of  the 
spine;  by  the  extended  superficial  dulness  on  percussion,  out  of 
proportion  to  the  extent  and  strength  of  the  pulsation  of  the  tumor, 
which  is  less  forcible  than  that  of  the  heart ;  by  the  displaced 
position  of  the  heart,  which  is  tilted  upward  and  thrown  over 
more  to  the  right;  and  especially  by  the  absence  of  any  signs  of 
pressure. 

The  signs  of  pressure  play,  then,  a  very  important  part  in  the 
diagnosis  of  an  aneurism.  They  are  rarely  absent,  although  they 
do  not  always  manifest  themselves  in  the  same  manner:  sometimes 
it  is  bone,  sometimes  lung,  sometimes  oesophagus,  sometimes  ner- 
vous fibre,  which  bears  the  brunt  of  the  distending  swelling.  These 
signs  of  pressure  are  wanting  if  the  sac  be  very  small  or  be  absent ; 
or  not  prominent  if  the  artery  be  simply  dilated,  in  which  case 
nothing  but  a  constantly  pulsating  tumor  can  be  detected.  Some- 
times evidences  of  compression  maybe  recognized  by  the  attentive 

*  Diseases  of  the  Heart,  London,  1876. 


THOEACIC    ANEURISM.  419 

physician  when  no  throbbing  swelling  can  be  discerned ;  and  from 
them  he  infers  the  true  nature  of  the  case,  although  utterly  unable 
to  discover  any  of  the  ordinary  physical  signs  of  an  aneurism. 
"Whenever,  indeed,  obstinate  and  anomalous  thoracic  symptoms, 
which  might  be  explained  by  the  presence  of  an  aneurismal  sac, 
occur  in  a  person  whose  lungs  and  heart  appear  to  be  in  every 
respect  sound  and  whose  general  health  is  not  materially  affected, 
we  may  suspect  an  aneurism  to  be  the  source  of  the  disorder. 
So,  too,  if  any  laryngeal  affection,  or  if  a  difficulty  in  swallow- 
ing, exhibit  rather  peculiar  symptoms.  It  is,  in  truth,  proper 
in  all  cases  of  chronic  disease  of  the  larynx,  or  where  there  are 
indications  of  a  stricture  of  the  oesophagus,  to  examine  the  chest 
carefully,  so  as  to  avoid  the  grave  error  of  overlooking  what 
may  be  the  only  cause  of  the  whole  disturbance. 

The  symptoms  of  chronic  laryngitis  especially  are  at  times  most 
astonishingly  simulated,  and  it  may  happen  that  the  patient,  trust- 
ing to  his  feelings,  refers  obstinately  to  the  chest  as  the  seat  of  the 
disorder,  while  the  physician  as  obstinately  sees  nothing  and  treats 
nothing  but  the  presumed  affection  of  the  larynx.  Even  if  we 
caunot  discern  any  pulsation,  the  following  signs  may  furnish  a 
key  to  the  case.  There  is,  as  in  chronic  laryngeal  disease,  altera- 
tion of  the  voice,  with  stridor,  and  peculiar  cough ;  but  the  voice 
is  not  so  uniformly  changed.  Often  it  retains  much  of  its  natural 
character ;  and  the  loss  is  not  so  progressive,  and  the  aphonia  not 
so  permanent.  Hoarse  the  voice  may  be,  but,  as  the  direction  of 
the  pressure  varies,  it  alters  rapidly  both  in  pitch  and  in  power. 
The  cough  is  most  commonly  loud  and  paroxysmal,  and  has  a 
ringing  sound.  Dyspnoea  is  a  very  constant  symptom,  and  is 
often  attended  with  wheezing  or  stridulous  breathing,  which  is 
not  persistent,  and  is  sometimes  only  produced  after  a  deep  in- 
spiration. The  stridor,  however,  as  Stokes  points  out,  differs 
from  that  of  an  obstructive  disease  of  the  larynx  by  its  seeming 
to  issue  from  the  notch  at  the  sternum,  and  not  from  above,  from 
the  larynx  itself.  If,  in  addition,  the  respiration  be  found  to  be 
markedly  unequal  in  the  two  lungs,  the  diagnosis  of  aneurism  may 
be  ventured  upon ;  and  it  will  be  confirmed  by  finding  no  change 
in  the  larynx,  when  examined  with  the  laryngoscope,  sufficient  to 
account  for  the  laryngeal  symptoms,  or  such  a  change — paralysis 
of  only  one  cord,  for  instance — as  could  be  readily  explained  by 


420  MEDICAL    DIAGNOSIS. 

pressure  on  one  recurrent  nerve.*  Of  course,  the  detection  of 
(1  ulness  on  percussion,  of  sounds  stronger  than  or  otherwise  dif- 
ferent from  those  in  the  cardiac  region,  or  the  occurrence  of  a 
hemorrhage,  would  place  the  diagnosis  beyond  doubt. 

In  some  cases  of  aneurism,  pain  is  among  the  earliest  symptoms, 
and  the  patient  complains  much  of  it  before  there  is  a  single  phys- 
ical sign  indicative  of  the  presence  of  a  tumor.  I  had,  several 
years  ago,  a  case  of  this  kind  under  my  care.  The  patient  suffered 
much  from  fugitive  chest-pains,  very  acute  and  violent.  He  had 
at  the  same  time  a  cough,  but  no  stridor.  The  respiration  in  both 
lungs  was  natural,  and  so  likewise  was,  as  far  as  could  be  ascer- 
tained, every  part  of  the  chest.  Dyspnoea  gradually  developed 
itself,  and  a  cough  with  a  metallic  clang  and  stridulous  breathing 
appeared,  while  a  pulsation  became  more  and  more  manifest 
immediately  below  the  notch  of  the  sternum. 

The  pain  is  dependent  upon  pressure  on  the  nervous  filaments : 
it  may  shoot  toward  the  shoulder  or  the  neck,  along  the  arm,  or 
deep  into  the  centre  of  the  chest.  Dull,  deep  pain,  boring  and 
constant,  is  prone  to  occur  when  the  pressure  of  the  sac  is  leading 
to  absorption  of  the  vertebra?.  Over  the  seat  of  the  swelling  there 
is  often  pain,  associated  with  great  tenderness. 

The  severity  of  the  pain  may  give  rise  to  emaciation  and  ex- 
haustion, and  become  a  cause  of  death ;  but  death  does  not  often 
take  place  from  exhaustion.  More  usually  the  patient's  life  is 
cut  short  by  the  aneurism  bursting,  either  externally  or  into 
internal  parts, — into  the  trachea,  bronchial  tubes,  oesophagus,  peri- 
cardium, pleura,  pulmonary  artery,  or  spinal  canal.  Yet  it  is  not 
always  the  first  rent  which  leads  to  the  fatal  issue;  this,  as  we 
learn  from  the  cases  that  Dr.  Webb|  has  analyzed,  may,  when  the 
aneurism  breaks  externally,  not  happen  for  weeks  after  the  accident. 

*  The  aphonia  in  aneurism  is  indeed  attributable  to  pressure  on  the  re- 
current laryngeal  nerve;  and,  as  mentioned  by  Tufnell,  a  stridulous  voice, 
unaccompanied  by  aphonia  and  dysphagia,  tends  to  show  that  the  tumor  is 
on  the  right  side  of  the  trachea  and  does  not  affect  the  oesophagus  or  the 
recurrent  laryngeal  nerve.  When  the  aneurism  presses  on  the  trachea  at  its 
bifurcation,  the  voice  will  be  raucous.  In  a  case  of  aortic  aneurism  recorded 
by  Habershon  (Medico-Chirurg.  Trans.,  1865),  the  aneurism  implicated  the 
left  recurrent  laryngeal  nerve,  and  there  was  atrophy  of  the  muscles  of  the 
larynx,  as  well  as  left-sided  pneumonia. 

t  American  Journal  of  the  Medical  Sciences,  Oct.  1874. 


THORACIC    ANEURISM.  421 

Now,  can  we  foretell  the  course  of  an  aneurism,  and  the  prob- 
able mode  of  death  it  is  likely  to  occasion  ?  We  cannot ;  for  in 
order  to  do  so  it  would  be  requisite  to  determine  accurately  its 
seat,  so  as  to  know  what  tissues  are  likely  to  be  encroached  upon. 
And  this  is  very  difficult,  nay,  often  impossible.  It  is  true  that, 
when  the  swelling  gives  rise  to  phenomena  like  those  of  angina 
pectoris,  we  may  surmise  it  to  be  in  the  ascending  portion  of  the 
aorta  and  near  the  cardiac  plexus  of  nerves,  and  look  for  its 
breaking  into  the  pericardium  or  the  pulmonary  artery;  when  it 
is  accompanied  by  laryngeal  stridor  or  other  laryngeal  symptoms, 
it  probably  involves  the  posterior  and  lower  portions  of  the  arch, 
and  will  cause  death  by  strangulation  or  by  exhaustion  ;  when  it 
produces  much  dyspnoea,  it  is  apt  to  be  seated  in  the  descending 
part  of  the  arch,  and  death  may  take  place  by  the  aneurism 
bursting  into  a  bronchial  tube,  or  by  pneumonia.  But  in  regard 
to  all  these  matters  we  can  usually  do  little  else  than  conjecture; 
because  a  tumor  within  the  chest  leads  to  such  displacements  that 
its  relations  to  the  surrounding  structures  cannot  be  clearly  ascer- 
tained durins;  life.  The  most  valuable  information  we  obtain  is 
from  a  study  of  the  physiological  changes, — from  the  symptoms, 
therefore,  of  disturbed  function ;  indeed,  the  correctness  of  our 
conclusions  will  depend  almost  entirely  on  that  of  our  interpreta- 
tion of  these  symptoms. 

An  aneurism  of  the  descending  aorta,  between  the  arch  and 
the  diaphragm,  produces,  if  extensive,  dulness  on  percussion  and 
bulging  posteriorly,  and  may  exhibit  the  same  physical  signs  and 
symptoms  as  an  aneurism  in  the  neighborhood  of  the  arch.  A 
gnawing  sensation  in  the  vertebrae  has  been  especially  noticed. 
Yet,  in  spite  of  the  most  careful  scrutiny,  an  aneurism  of  the 
descending  aorta  often  escapes  detection,  or  its  physical  signs,  as  a 
case  recorded  by  Walshe*  proves,  may  exist  to  the  right  instead 
of  to  the  left  of  the  spinal  column,  because  the  vessel  has  been 
dragged  across  the  median  line  by  its  enlargement,  and  thus  very 
considerable  doubt  may  be  thrown  upon  the  diagnosis. 

An  aneurism  of  the  heart  may  in  exceptional  instances  produce 
localized  bulging  in  the  cardiac  region.  But  wdiether  it  does  so  or 
not,  it  is  beyond  the  reach  of  positive  diagnosis. 

*  Diseases  of  the  Heart. 


422  MEDICAL    DIAGNOSIS. 

Let  us,  in  conclusion,  glance  at  the  other  kinds  of  aneurism 
within  the  thorax, — that  of  the  innominate  and  that  of  the  pul- 
monary artery. 

An  aneurism  of  the  innominate  artery  is  strictly  limited  to  the 
right  side  of  the  body.  It  differs  from  that  of  the  arch  by  the 
higher  situation  of  the  pulsating  swelling ;  by  the  displacement  of 
the  clavicle;  by  the  comparative  absence  of  signs  of  pressure  on 
the  larynx  and  oesophagus ;  and  by  the  fact  that  compression  of 
the  right  subclavian  and  carotid  diminishes  the  beat  of  the  tumor, 
while  it  exerts  no  effect  on  an  aortic  aneurism.  Such  are,  at  all 
events,  the  marks  of  distinction  indicated  by  the  observations  in 
Holland's*  excellent  memoir.  An  additional  sign  is  mentioned  by 
Wardrop.f  It  is  that  when  the  innominate  is  affected,  the  diffi- 
culty will  appear  first  on  the  tracheal  side  of  the  sterno-mastoid ; 
but  on  the  cervical  side  if  the  aneurism  be  of  the  subclavian. 

An  aneurism  of  the  pulmonary  artery  is  a  rare  disease.  Its 
main  phenomena,  so  far  as  the  few  cases  on  record  enable  us  to 
judge, are:  a  strongly  pulsating  swelling,  perceptible  to  the  left  of 
the  sternum,  and  limited  to  the  second  intercostal  space  near  the 
costal  cartilages ;  a  marked  thrill  occurring  with  each  expansion 
of  the  aneurism ;  and  in  some  instances  a  rough  murmur,  which 
is  not  discovered  at  the  notch  of  the  sternum  or  above  the  clavi- 
cles ;  lividity  of  face ;  dropsy ;  and  great  difficulty  of  breathing.^ 
The  most  significant  points  of  difference  between  an  aneurism 
of  the  pulmonary  artery  and  of  the  aorta  consist  in  the  symptoms 
just  alluded  to,  and  in  the  absence  of  obvious  evidences  of  pressure. 
The  situation,  too,  of  the  physical  phenomena  is  important;  yet 
we  must  bear  in  mind  that  an  aneurism  of  the  arch  may  occasion 
a  pulsating  tumor,  mainly  to  the  left  of  the  sternum,  and  may 
even  break  into  the  pulmonary  artery.  A  mere  distinct  beating 
of  the  pulmonary  artery  is  discriminated  from  an  aneurism  of  this 
vessel  by  the  non-existence  of  a  palpable  swelling,  of  dropsy,  of 
greatly  embarrassed  breathing,  of  lividity  of  the  face,  and  by  the 
usually  coexisting  signs  of  some  consolidation  of  the  left  lung. 

*  Dublin  Quarterly  Journal,  vol.  xii. 

f  Holmes's  Surgery,  vol.  iii.  p.  562. 

X  In  the  case  detailed  by  Skoda  (Auscultation  and  Percussion),  the  dropsy 
was  very  great,  and  the  face  cyanotic  ;  there  was  a  faint  murmur  over  the 
base  of  the  heart,  but  none  over  the  pulmonary  artery. 


CHAPTEE    V. 

DISEASES   OF   THE   MOUTH,  PHAEYNX,  AND  (ESOPHAGUS. 

The  diseases  of  this  part  of  the  digestive  system  need  not  here 
be  described  at  any  length,  because  many  of  them  have  already 
been  considered  in  treating  of  the  affections  of  the  larynx,  and  of 
the  heart  and  great  vessels. 

MOUTH. 

Soreness  of  the  mouth,  pain  in  masticating,  and  a  fetid  breath 
are  often  complained  of  in  diseases  of  the  oral  cavity.  Let  us 
suppose  a  patient  to  present  himself  with  such  symptoms.  The 
interior  of  the  mouth  is  exposed  to  a  strong  light,  and  its  different 
parts  inspected. 

The  gums  are  noticed  to  be  swollen  and  injected,  and  the  mucous 
membrane  lining  the  cheeks  reddened. — This  is  a  state  of  things 
observed  in  the  different  forms  of  stomatitis.  In  the  common 
diffused  inflammation,  the  result  of  direct  irritation,  such  as  of 
the  swallowing  of  hot  liquids  or  of  corrosive  substances,  or  an 
accompaniment  and  consequence  of  gastric  disorder,  the  redness 
is  very  marked ;  any  attempt  at  chewing  is  painful ;  the  taste  is 
impaired;  a  flow  of  saliva  takes  place  from  the  mouth,  and  super- 
ficial ulcerations  occur  at  its  various  parts.  In  mercurial  stoma- 
titis there  are  much  the  same  symptoms;  but  the  more  copious 
discharge  of  saliva,  the  pain  in  the  jaws,  the  loosening  of  the 
teeth,  the  enlarged  tongue,  exhibiting  their  impress,  the  painful 
and  swollen  state  of  the  salivary  glands,  and,  above  all,  the  pecu- 
liar nauseous  breath,  testify  to  the  specific  character  of  the  inflam- 
mation. The  sore  mouth  of  scurvy  may  be  distinguished  from 
either  of  the  preceding  forms  by  the  spongy,  purplish,  or  livid 
gums,  which  bleed  on  the  slightest  touch,  by  the  eruption  on  the 
skin,  and  by  the  other  signs  which  attend  a  scorbutic  state. 

The  gums  and  the  inside  of  the  cheeks  and  lips  are  covered  ivith 

423 


424  MEDICAL    DIAGNOSIS. 

a  whitish  curd-like  exudation. — This  constitutes  the  form  of  stom- 
atitis known  as  thrush,  so  frequent  in  infants  at  the  breast,  and  so 
constantly  associated  with  intestinal  disorder,  with  diarrhoea,  with 
colicky  pains,  and  with  a  feverish  heat  of  skin  and  a  hot,  dry 
mouth.  Very  similar  to  it,  regarded  indeed  by  some  as  identical, 
is  the  aphthous  ulceration,  to  which  adults  as  well  as  children  are 
liable.  Here,  too,  a  whitish  deposit  is  perceived  in  various  parts 
of  the  mouth ;  it  is  apt  also  to  be  combined  with  thirst  and  with 
gastric  or  intestinal  disturbance,  and  the  breath  has  a  very  disagree- 
able smell.  The  recognized  difference  consists  in  the  presence  of 
the  small  ulcers  which  may  be  detected  when  the  white  crusts  that 
cover  them  are  removed,  and  in  the  vesicular  nature  of  the  disease 
during  its  formative  stage.  Then  more  or  less  redness  surrounds 
each  spot,  the  ulcers  are  slightly  raised  at  their  borders,  bleed 
easily  on  pressure,  and  may  be  irregular  from  several  running 
together;  their  grayish  covering  is  found  to  be  soluble  in  ether, 
and  to  present  many  oil-globules  under  the  microscope.  On  the 
other  hand,  this  instrument  shows  us  in  thrush  a  special  parasitic 
formation,  the  oidium  albicans. 

Ulcerations  are  perceived  on  the  gums,  tongue,  and  various  parts 
of  the  mouth. — We  meet  with  ulcers  in  the  ordinary,  in  the  mer- 
curial, in  the  scorbutic,  and  in  the  aphthous  inflammation  of  the 
mouth.  But  ulceration  is  apt  to  exhibit  its  most  horrible  features 
in  the  sore  mouth  of  syphilis,  and  in  that  essentially  ulcerative 
disease  called  cancrum  oris,  or  ulcerative  stomatitis.  In  the  for- 
mer, the  fauces  as  well  as  the  mouth  are,  as  a  general  rule,  involved, 
and  the  ulcers  show  peculiarities  which  we  shall  presently  study. 
The  latter  is  an  affection  which  prevails  especially  in  enfeebled 
constitutions.  It  is  seen  chiefly  in  hospitals,  and  not  uncommonly 
in  epidemics.  It  begins  with  pain  in  the  gums,  and  these  soon 
swell,  redden,  and  bleed  readily.  They  are  covered  with  a  soft, 
grayish  exudation,  which  often  extends  to  the  soft  palate.  If  the 
layer  of  exudation  be  scraped  away,  a  bleeding,  ulcerated  mucous 
membrane  comes  into  view,  provided  the  swelling  be  not  so  great 
as  to  render  a  careful  examination  of  the  mouth  impossible.  The 
breath  is  most  offensive;  there  is  usually  fever;  yet  the  disease 
does  not  uniformly  progress  with  activity  :  it  may  last  for  weeks, 
or  even  for  months.  Owing  to  the  ulceration  and  to  the  extreme 
fetor  of  the  breath,  it  is  often  mistaken  for  gangrene  of  the  mouth. 


DISEASES    OP    THE    MOUTH,    PHARYNX,    ETC.  425 

But  although  it  may  terminate  in  gangrene,  it  does  not  do  so  of 
necessity.  It  is  a  far  less  serious  complaint,  runs  a  less  speedy 
course,  presents  a  breath  fetid  it  is  true,  but  not  of  the  peculiar 
gangrenous  odor,  and  lacks  the  very  symptoms  which  gangrene 
within  the  mouth  gives  rise  to, — the  rapid  extension  of  the  ulcera- 
tion ;  the  dark-gray  tint  around  it ;  the  extensive  swelling  of  the 
cheek ;  its  altered  color  and  partial  destruction ;  the  constant  and 
profuse  flow  from  the  mouth  of  blood  or  pus  mixed  with  saliva ; 
and  the  laying  bare  of  the  bones  and  loosening  of  the  teeth. 

The  tongue  is  red  and  swollen. — Changes  in  color  and  in  ap- 
pearance of  the  tongue  occur  in  general  diseases  of  the  system, 
and  more  especially  in  those  of  the  alimentary  canal.  The  tongue 
is  also  more  or  less  involved,  at  all  events  its  mucous  membrane 
is,  in  the  different  forms  of  stomatitis.  An  abnormal  state  of  the 
covering  of  the  tongue  is,  therefore,  far  from  being  a  sign  that  the 
organ  itself  is  primarily  affected. 

Occasionally,  however,  we  do  meet  with  affections  of  its  deeper 
structures.  Its  nerves  may  be  the  seat  of  violent  neuralgia ;  its 
muscles  may  be  paralyzed ;  it  may  become  hypertrophied  or  can- 
cerous ;  it  may  undergo  progressive  atrophy ;  or  it  may  be  in  a 
state  of  acute  inflammation.  The  latter  is,  perhaps,  the  most 
frequent  of  its  maladies,  and  is  readily  recognized  by  the  red, 
swollen  look  of  the  organ,  joined  to  a  burning  pain  in  it,  and 
either  to  great  dryness  of  the  mouth  or  to  constant  dribbling. 
The  swelling  usually  begins  at  the  anterior  portion,  and  may 
become  so  considerable  as  to  threaten  suffocation ;  the  inflamed 
tongue  fills  up  the  fauces  and  protrudes  out  of  the  mouth,  and 
the  unhappy  patient  can  neither  swallow  nor  utter  a  word.  He 
has  active  fever,  headache,  great  restlessness,  and  intense  thirst, 
which  symptoms  last  for  several  days,  and  until  the  inflammation 
subsides.  But  unless  properly  treated,  and  sometimes  in  spite  of 
proper  treatment,  the  inflammation  is  likely  not  to  end  in  resolu- 
tion, but  runs  on  to  suppuration  or  gangrene.  In  some  instances 
it  leaves  a  permanent  induration,  which  may  be  mistaken  for  a 
cancerous  nodule.  Acute  glossitis  is  a  dangerous  complaint;  for- 
tunately, it  is  a  rare  one.  Its  most  frequent  cause,  as  now  seen, 
is  direct  injury,  either  from  wounds  or  the  stings  of  venomous 
insects,  or  from  the  introduction  of  corrosive  substances  into  the 
mouth.     Its  most  frequent  cause  formerly  was  the  abuse  of  mer- 


426  MEDICAL    DIAGNOSIS. 

cury  pushed   to  salivation.     At  times  it  is  observed  as  a  com- 
plication of  scarlatina  and  of  erysipelas. 

FAUCES. 

The  fauces — that  is,  the  parts  at  the  back  of  the  mouth  which 
are  brought  into  view  when  the  lips  are  widely  opened,  such  as 
the  half-arches,  the  uvula,  the  tonsils,  the  posterior  wall  of  the 
pharynx — may  be  involved  in  the  same  diseases  as  the  parts  situ- 
ated in  front.  The  contiguity  of  these  structures  is  in  fact  such 
that  any  morbid  action  is  apt  to  spread  to  them,  or  to  extend  from 
them  either  forward  or  downward  into  the  pharynx,  and  even  into 
the  larynx.  Moreover,  on  this  very  account  a  disorder  is  rarely 
found  limited  to  any  one  portion  of  the  fauces,  but  transfers  itself 
generally  from  one  to  the  other,  from  the  tonsils  to  the  soft  pal- 
ate, from  the  soft  palate  to  the  tonsils.  The  most  common  affec- 
tions of  the  fauces  are  inflammation  and  ulceration,  both  of  which 
occasion  a  feeling  of  uneasiness  in  the  throat,  and  also  difficulty 
or  pain  in  deglutition,  and  both  of  which  are  readily  enough 
detected  by  looking  into  the  mouth  when  the  jaws  are  widely 
separated  and  the  tongue  depressed. 

In  the  ordinary  inflammation  of  the  fauces,  the  simple  angina, 
or  sore  throat,  the  parts  are  of  a  bright-red  color,  and  the  uvula  is 
long  and  swollen,  and  by  dropping  on  the  tongue  gives  rise  to  a 
constant  disposition  to  swallow,  although  the  act  of  swallowing  is 
attended  with  pain.  Associated  with  the  angina  are  coryza  and 
febrile  disturbance;  and,  owing  to  the  inflammation  travelling  up 
the  Eustachian  tube,  the  sense  of  hearing  is  impaired. 

The  same  symptoms  are  observed  in  the  pseudomembranous 
inflammation  of  the  fauces;  but  we  find  here,  as  when  describing 
diphtheria  we  shall  make  apparent,  patches  of  exudation. 

Tonsillitis. — When  the  inflammation  penetrates  the  substance 
of  the  tonsils,  occasioning  the  disease  popularly  known  as  quinsy, 
much  the  same  general  symptoms  occur  as  in  ordinary  angina. 
But  the  sense  of  constriction  in  the  throat  is  greater;  so  is  the 
difficulty  in  swallowing ;  and  liquids  are  apt  to  return  through 
the  nose.  The  voice  is  thick,  and  has  often  a  peculiar  sound  ; 
it  is  painful  to  the  patient  to  talk,  and  on  looking  into  the  throat 
the  tonsils  may  be  seen  red,  prominent,  and  covered  with  mucus 


DISEASES    OF    THE    MOUTH,   PHAKYNX,    ETC.  427 

which  is  not  easily  detached.  Sometimes  the  swelling  is  so  con- 
siderable that  the  tumid  glands  fill  up  the  space  between  the 
half-arches  and  leave  but  a  small  interval  for  the  passage  of  food 
or  drink.  In  some  instances  we  cannot  separate  the  jaws  suffi- 
ciently to  get  a  view  of  the  throat,  and  have  to  trust  to  the  intro- 
duction of  the  finger  to  tell  us  the  condition  of  the  affected  parts. 
Occasionally  the  inflammation  extends  from  the  tonsils  to  the 
salivary  glands ;  the  submaxillary  and  parotid  glands  swell,  and 
ptyalism  takes  place.  It  is  necessary  to  be  aware  of  this  fact; 
for,  if  a  mercurial  cathartic  has  been  administered,  the  profuse 
flow  of  saliva  might  be  incorrectly  attributed  to  it. 

There  is  not  much  likelihood  of  confounding  this  secondary 
parotitis  with  mumps,  in  which  an  outward  swelling,  visible  be- 
neath the  ear,  is  found,  but  not  a  swelling  within  the  throat,  and 
in  which  no  real  difficulty  in  swallowing  occurs,  except,  perhaps, 
when  the  tumefaction  is  at  its  height.  This  comparative  absence 
of  difficulty  in  deglutition,  added  to  the  tension,  fulness,  and 
soreness  at  the  angles  of  the  jaw,  the  pain  felt  there,  the  almost 
impossible  mastication,  the  purely  external  character  of  the  tume- 
faction, and  the  febrile  excitement  and  disfigured  face,  are  indeed 
the  signs  by  which  parotitis  is  generally  at  once  distinguished 
from  any  of  the  morbid  states  which  resemble  it. 

Tonsillitis  terminates  by  resolution  or  by  the  formation  of  pus. 
There  are  no  positive  means  of  ascertaining  that  the  inflammation 
is  going  to  end  in  suppuration,  although  we  may  suspect  that  this 
will  be  the  case  when  much  pain  is  felt  at  the  angles  of  the  jaws 
and  shooting  to  the  ear,  and  when  the  symptoms  have  been  severe 
and  persistent  for  more  than  four  or  five  days.  Sometimes  the  pus 
may  be  seen  through  the  covering  of  the  tonsils;  but  often  the 
vast  sense  of  relief  experienced  by  the  patient,  and  the  sudden 
improvement  in  deglutition,  attended,  perhaps,  with  an  unpleas- 
ant taste,  are  the  only  signs  that  the  collection  of  pus  has  been 
discharged.  Attacks  of  tonsillitis  are  prone  to  be  repeated,  and 
may  lead  to  permanent  enlargement  and  induration  of  the  tonsils. 
The  enlarged  tonsils,  attended  as  they  frequently  are  with  cervical 
glandular  swellings,  may  be  mistaken  for  cancer  of  the  tonsils. 
But  in  this  affection  sanious  offensive  ulcerations  occur.* 

*  Poland,  Brit,  and  For.  Med.-Chir.  Rev.,  April,  1872. 


428  MEDICAL    DIAGNOSIS. 

Diphtheria. — There  is  another  kind  of  inflammation  of  the 
fauces  which,  in  obedience  to  the  clinical  classification  followed  in 
this  work,  may  be  considered  here, — membranous  angina  or  diph- 
theria. Not  that  it  is  really  a  local  malady.  On  the  contrary,  it 
is  a  general  disease,  of  which  the  exudative  inflammation  of  the 
throat  is  merely  the  most  usual  characteristic.  Yet  the  local  lesion 
is  so  marked,  and  the  symptoms  are  so  nearly  related  to  those  of 
the  common  forms  of  acute  sore  throat,  that  practically  the  dis- 
order is  best  regarded  in  connection  with  them. 

It  begins  usually  as  an  ordinary  sore  throat,  with  redness  and 
swelling  of  the  arches  of  the  palate,  and  of  the  tonsils.  There  is 
a  slight  stiifness  of  the  neck,  and  the  cervical  and  submaxillary 
glands  of  the  jaw  are  enlarged  and  tender,  and  the  subcutaneous 
tissue  may  become  involved  in  the  swelling.  Within  a  period 
varying  from  a  few  hours  to  a  few  days,  an  exudation  takes  place 
on  the  tonsils,  the  uvula,  and  the  soft  palate.  This  exudation  is 
more  or  less  extensive,  generally  tough,  and  of  a  white  or  grayish 
hue.  It  may  show  but  little  tendency  to  spread ;  or  it  may  ex- 
tend to  the  gums  and  along  the  walls  of  the  pharynx,  and  into  the 
windpipe.  In  some  cases  it  passes  upward  into  the  nares,  yet  it 
may  begin  there  simultaneously  with  its  appearance  in  the  throat. 
The  false  membrane,  once  formed,  darkens,  wastes  from  the  cir- 
cumference toward  the  centre,  and  gradually  disappears.  But 
sometimes  the  coat  becomes  for  a  time  thicker  and  thicker  by  the 
constant  addition  of  fresh  layers.  This  happens  particularly  in 
the  "croupous  form"  of  diphtheria,  in  which  the  inflammation  is 
more  intense  from  the  onset,  and  fibrin  is  freely  poured  out,  not 
simply  into  the  epithelium,  but  into  the  tissues  underneath,  and 
in  which  the  fibrinous  exudations  succeed  one  another  rapidly 
until  the  dense  thick  coating  of  false  membrane  results.  Under 
any  circumstances,  when  artificially  removed,  the  pseudomem- 
brane  is  soon  developed.  After  the  first  week  from  its  beginning, 
no  further  exudation  is  apt  to  happen,  and  the  danger  arising 
from  the  membrane  may  be  generally  looked  upon  as  over,  unless, 
as  is  not  uncommon,  a  relapse  of  the  malady  occur. 

The  constitutional  symptoms  vary  greatly  in  different  cases. 
The  pulse  may  be  frequent,  the  skin  hot,  and  there  may  be  much 
pain  in  the  head ;  in  fact,  the  symptoms  are  those  of  asthenic 
fever,  with  considerable  elevation  of  temperature.     Yet  generally 


DISEASES    OF    THE    MOUTH,    PHARYNX,    ETC.  429 

there  is  little  febrile  excitement,  but  a  sense  of  weakness  and  pros- 
tration are  prominent  from  the  onset.  In  some  instances,  typhoid 
phenomena  show  themselves,  especially  in  those  instances  in  which 
decomposition  of  the  disintegrating  exudation  takes  place,  giving 
rise  to  the  septic  form  of  the  malady;  in  this  the  temperature 
may  be  even  below  the  normal.  The  more  asthenic  the  disorder, 
the  more  apt  is  the  exudation  to  be  pulpy  and  granular. 

In  diphtheria  the  danger  is  twofold  :  it  arises  partly  from  the 
depressing  effect  of  the  poison,  increased  as  this  effect  may  be  by 
the  absorption  of  putrid  matter  from  the  throat ;  partly  from  the 
extension  of  the  disease  to  the  larynx  and  lungs.  Again,  at  the 
height  or  even  at  the  decline  of  the  malady  there  is  risk  of  heart- 
palsy  or  heart-clot.  Nor  is  the  termination  of  the  acute  disorder 
always  the  termination  of  the  complaint.  A  chronic  irritation  of 
the  throat,  lasting  weeks  or  months,  and  possibly  relapsing,  under 
exposure,  into  a  diphtheritic  sore  throat,  remains ;  or  albuminuria, 
which,  indeed,  shows  itself  during  the  height  of  the  malady,  but 
which  also  outlasts  its  acute  manifestations;  or  pleurisy,  or  bron- 
chitis and  pneumonia — both  of  which  may  be  delayed  until  after 
the  exudation  has  disappeared  from  the  throat — increase  the  list 
of  the  complications  of  the  affection,  and  protract  or  imperil  the 
convalescence.  And  there  are  morbid  conditions  which  may  be 
wholly  looked  upon  as  after-symptoms.  A  paralysis  of  the  velum 
palati  and  of  the  pharyngeal  arches,  making  itself  apparent  by 
a  peculiar  nasal  intonation  of  the  voice,  and  by  proneness  to  re- 
gurgitation of  fluids  through  the  nostrils,  is  among  the  earliest  of 
them,  showing  itself  often,  indeed,  just  at  the  termination  of  the 
acute  malady.  Later  appear  impairment  of  vision,  gastrodynia, 
ulcers  in  various  parts  of  the  body,  profound  anaemia,  and  that 
gradual  failing  of  muscular  power  with  numbness  which  ordi- 
narily does  not  take  place  until  after  complete  convalescence,  and 
which  winds  up  in  almost  total,  although  not  irremediable,  loss 
of  muscular  force, — in  diphtheritic  paralysis.  Furthermore,  I 
have  known  aphasia  to  follow  the  depressing  complaint. 

Now,  all  these  facts  indicate  the  malignant  character  of  the  dis- 
ease, and  how  essential  it  is,  even  while  the  malady  is  in  its  acute 
stage,  to  counteract,  by  nourishment  and  stimulants,  the  exhaust- 
ing effect  of  the  poison ;  how  essential  to  continue  the  treatment 
long  after  the  throat  affection  has  been  removed. 


430  MEDICAL    DIAGNOSIS. 

But  to  look  at  the  differential  diagnosis  of  the  disorder.  It 
varies  widely  from  stomatitis,  from  tonsillitis,  from  pharyngitis, 
— in  truth,  from  all  the  ordinary  local  inflammations  of  these 
structures, — by  the  presence  of  a  membrane,  by  the  striking  con- 
stitutional symptoms,  and  by  the  sequela?. 

Yet  there  are  certain  sources  of  error  against  which  it  is  neces- 
sary to  guard.  In  simple  pharyngitis,  a  mass  of  mucus,  in  part 
derived  from  the  nares,  is  apt  to  collect  on  the  inflamed  mem- 
brane, and  looks  at  first  sight  like  the  coating  from  an  exudation; 
but  it  may  be  easily  removed,  and  a  closer  inspection  proves  its 
true  nature.  In  tonsillitis,  liquid  may  ooze  from  the  opening  of 
the  follicles  on  the  surface  of  the  swollen  tonsils,  or  little  yellow- 
ish or  whitish  points  form  there.  But  they  are  very  limited,  are 
strictly  confined  to  the  gland,  exhibit  no  tendency  to  spread  or  to 
coalesce,  are  generally  small  white  specks  of  roundish  or  oval 
shape,  and,  when  cast  off,  superficial  ulcerations  are  seen  on  the 
gland.  I  desire  particularly  to  call  attention  to  the  possibility  of 
confounding  these  appearances,  which  are  by  no  means  uncommon 
in  some  forms  of  tonsillitis,  with  diphtheria,  for  I  have  known 
them  to  occasion  more  than  one  mistake.  The  mistake  is  most 
likely  to  happen  in  those  mild  cases  of  the  disease  in  which  the 
exudation  is  limited,  and  the  injection  or  superficial  inflammation 
of  the  tonsils  and  back  of  the  throat  marked,  which  are  some- 
times described  as  the  "catarrhal  form"  of  diphtheria.  Should, 
in  an  individual  instance,  the  facts  mentioned  be  insufficient  to 
solve  the  doubt,  the  microscope  can  do  so  readily;  for  it  shows 
the  white  masses  to  be  largely  composed  of  epithelium,  and  not, 
like  the  diphtheritic  membrane,  mainly  of  fibrillated  fibrin,  of 
granular  corpuscles,  and  of  pus,  besides  epithelium  in  different 
degrees  of  development  and  retrograde  change,  and  fungoid 
masses.*  Even  on  the  most  superficial  layers  of  the  epithelium 
round-celled  vegetable  organisms,  micrococci,  show  themselves  at 
once;  these  penetrate,  recent  observers  tell  us,  into  the  deeper 
layers,  by  what  Oertel  calls  a  micrococcus  vegetation,  and  this 
vegetation  is  supposed  to  be  the  causing  element,  the  very  essence, 
of  diphtheria. 

Ulcerative  stomatitis,  the  form  of  stomatitis  most  likely  to  be 

-  Senator,  Klinische  Vortrage,  1874. 


DISEASES    OF    THE    MOUTH,   PHAEYNX,   ETC.  431 

confounded  with  diphtheria,  and  especially  with  this  malady  when 
the  exudation  lines  the  gums,  is  discriminated  by  the  ulceration 
or  sloughing ;  whereas  the  mucous  membrane  in  the  pseudomem- 
branous disease  remains  intact,  save  in  the  rarest  instances.  The 
same  feature  distinguishes  diphtheria  from  gangrene  of  the  mouth, 
for  which,  on  account  of  the  extreme  fetor  of  the  breath,  it  is  some- 
times mistaken,  and  aids  in  distinguishing  it  also  from  other  kinds 
of  stomatitis,  as  from  thrush.  In  the  latter,  too,  the  buccal  mucous 
membrane,  and  not  the  throat,  is  chiefly  affected,  and  the  abdom- 
inal symptoms,  and  the  other  constitutional  phenomena,  are  dif- 
ferent. So  are  they  in  aphthce,  in  which,  moreover,  the  superficial 
ulcerations,  which  bleed  when  touched,  the  unbroken  vesicles  or 
pustules  in  other  parts,  and  the  seat  of  the  disorder — usually  on 
the  edge  of  the  tongue,  on  the  internal  surface  of  the  lips,  and  on  the 
gums  and  inside  of  the  cheek — are  points  to  be  taken  into  account. 

Besides  these  affections,  there  are  others  which  must  be  distin- 
guished from  diphtheria.  We  occasionally  find  cases  occurring 
in  epidemics,  and  where  the  membrane  is  limited  nearly  altogether 
to  the  follicles,  and  chiefly  to.  the  tonsils.  As  the  membrane 
passes  away,  ulcerations  are  obvious.  Swelling  of  the  glands 
of  the  neck,  and  fever,  but  not  of  acute  type,  attend  this  ulcero- 
■  membranous  angina,  which,  moreover,  shows  a  strong  disposition 
to  relapses.  But,  though  kindred  to  diphtheria,  and  in  isolated 
instances  perhaps  difficult  to  discriminate,  it  differs  from  it  in  its 
seat  and  in  its  want  of  tendency  to  spread,  in  the  formation  of 
superficial  ulcers,  in  its  less  marked  constitutional  depression,  and 
in  its  invariably  favorable  termination.*  Whether  there  be  not 
also  other  kinds  of  membranous  sore  throat  to  be  separated  from 
true  diphtheria,  is  a  matter  requiring  further  investigation. 

There  is  an  acute  disease  of  the  throat  to  which  Todd  especially 
has  called  attention,  f  and  which  presents  also  some  strong  points 
of  similitude  to  diphtheria, — erysipelas  of  the  fauces.  Like  diph- 
theria, it  is  a  most  dangerous  ailment;  as  in  diphtheria,  the 
morbid  process  may  extend  to  the  larynx ;  as  happens  often  in 
diphtheria,  the  mucous  membrane  may  exhibit  a  peculiar  dusky- 
red  color;  as  in  diphtheria,  the  poison  paralyzes  the  muscles  of 

*  See  a  paper,  in  which  I  have  described  an  epidemic  of  the  kind,  in  the 
Amer.  Jour,  of  Med.  Sci.,  July,  1870. 
■j-  Clinical  Lectures  on  Acute  Diseases. 


432  MEDICAL    DIAGNOSIS. 

the  palate  and  pharynx,  and  liquids  are  apt  to  be  rejected  through 
the  nostrils  and  month.  Bnt  the  difficulty  in  deglutition  differs 
from  that  of  diphtheria  in  being  present  from  the  onset,  and  is 
not  attended  with  enlargement  of  the  glands  of  the  neck,  or  with 
the  formation  of  a  false  membrane.  In  some  instances,  too,  we 
find  vivid  redness  of  the  throat,  which  may  be  associated  with 
much  swelling.  If  the  erysipelatous  inflammation  extend  to  the 
larynx,  there  is  local  pain,  with  urgent  dyspnoea  and  hoarseness; 
and  usually  rapid  exhaustion  supervenes.  In  cases  of  this  kind, 
the  submucous  tissues  of  the  larynx  are  found  extensively  infil- 
trated with  pus.  The  cases  may  happen  without  erysipelas  show- 
ing itself  on  any  external  part  of  the  body ;  on  the  other  hand, 
erysipelas  beginning  in  the  fauces  may  spread  to  the  face.* 

This  erysipelas  of  the  fauces  is  not  a  frequent  disease;  and  it 
must  be  stated  that  there  are  cases  of  diphtheria  which  simulate 
it  very  closely.  I  have  seen  a  number  of  instances  of  the  malady 
in  which  the  whole  mucous  membrane  was  of  a  vivid  or  dusky 
hue ;  in  which  there  was  much  swelling,  with  an  effusion  of  serum, 
especially  in  the  submucous  tissue  of  the  uvula,  causing  it  to  look 
like  a  small  transparent  bag;  in  which  immense  difficulty  or  even 
impossibility  in  deglutition  existed, — yet  in  which  no  membrane 
appeared  for  days  after  the  violent  inflammation  of  the  throat  had 
set  in,  and  was,  when  it  showed  itself,  very  slight  in  extent,  and 
out  of  all  proportion  to  the  inflammation.  But  the  constitutional 
symptoms  and  the  sequela?  were  the  same  as  those  of  ordinary 
diphtheria.  In  one  of  the  cases  of  the  kind  referred  to,  suppu- 
ration of  one  of  the  tonsils  took  place  in  consequence  of  the 
inflammation ;  a  layer  of  deposit  had  coated  parts  of  the  tonsils 
and  of  the  half  arches  and  uvula. 

How  shall  we  separate  diphtheria  from  membranous  croup,  a 
disease  with  which,  indeed,  it  is  by  many  regarded  as  identical? 
Yet  this  seems  taking  a  narrow  view  of  the  facts.  In  the  first 
place,  croup  is  a  local  complaint,  and  lacks  the  peculiar  constitu- 
tional symptoms,  the  early  depression  and  the  sequelae  of  diphthe- 
ria. Secondly,  an  affection  of  the  windpipe  is  not  by  any  means 
an  essential  element  of  diphtheria,  for  in  the  majority  of  cases  the 
disease  does  not  spread  to  the  larynx.     Thirdly,  when,  from  the 

*  Cases  quoted  in  Schmidt's  Jahrbiicher,  1809,  Xo.  1. 


DISEASES    OF    THE    MOUTH,    PHARYNX,    ETC.  433 

paroxysms  of  hoarse,  irritative  cough,  the  labored  breathing,  the 
attacks  of  suffocation,  the  huskiness  or  extinction  of  voice,  we  may 
infer  that  the  exudative  process  has  reached  the  larynx, — when,  in 
other  words,  the  symptoms  of  croup  arise, — we  still  recall  that  the 
first  manifestations  of  the  membranous  affection  were  perceived  in 
the  throat,  and  not  in  the  larynx.  Indeed,  save  in  the  rarest 
cases,  and  even  these  are  not  all  free  from  doubt,  the  disease  does 
not  begin  in  the  windpipe ;  though  the  beginning  above  may  not 
attract  attention,  and  may  be  most  readily  overlooked.  Thus, 
laryngeal  diphtheria  affects  primarily  the  throat,  and  may  extend 
to  the  windpipe ;  pseudomembranous  croup  affects  primarily  the 
windpipe,  and  may  extend  to  the  throat.  Fourthly,  croup  is  not 
contagious,  as  we  find  diphtheria  is.  And,  even  granting  that  as 
regards  the  membrane  and  the  symptoms  we  may  not  be  able,  as 
indeed  we  are  sometimes  not  able,  to  distinguish  individual  cases 
of  membranous  croup  from  laryngeal  diphtheria,  the  origin  of  the 
diphtheritic  complaint,  and  its  spreading  to  other  members  of  the 
household,  if  not  in  a  membranous  form  yet  in  the  form  of  sore 
throat  with  singular  constitutional  depression,  show  its  peculiar 
and  special  traits. 

On  one  symptom  we  cannot  lay,  we  now  know,  as  much  stress 
as  might  be  supposed.  The  albuminuria,  the  recent  elaborate  re- 
port of  the  committee  of  the  Medico-Chirurgical  Society  has 
taught  us,*  is  not  always  present  in  laryngeal  diphtheria,  owing  to 
the  early  fatality  of  the  malady ;  again,  in  certain  cases  the  mere 
dyspnoea  of  laryngitis  may  give  rise  to  albumen  in  the  urine. 
Yet  when  albuminuria  is  marked,  and  when  it  has  happened 
where  an  affection  of  the  fauces  has  preceded  the  laryngeal  im- 
plication, it  points  to  an  infective  or  zymotic  cause, — to  laryngeal 
diphtheria.  But  it  is  fair  to  add  that  even  with  reference  to 
the  cause,  the  committee  admits  for  a  much  larger  number  of 
cases,  such  as  would  be  generally  called  membranous  croup,  a 
starting-point  in  a  general  or  an  epidemic  influence,  and  attaches  far 
less  importance  to  its  origin  in  cold  than  has  been  generally  done. 

Lastly,  diphtheria  may  be  confounded  with  scarlatina.  When, 
indeed,  we  reflect  on  the  similar  appearance  of  the  throat,  on  the 
occurrence  of  albuminuria  in  both  maladies,  and  on  the  frequency 


*  Medico-Chirurgical  Transactions,  vol.  lxii.,  1879. 
28 


434  MEDICAL    DIAGNOSIS. 

with  which  both  are  found  to  prevail  at  the  same  time  as  epidemics 
in  a  community,  it  is  not  astonishing  that  one  should  be  looked 
upon  as  but  a  modified  form  of  the  other.  Allied  they  certainly 
are,  but  not  identical ;  for  the  poison  of  one  leads  to  a  thoroughly 
defined  rash,  and  leaves  a  protective  influence  against  a  second 
attack,  and  often  also  deafness,  suppuration  of  the  glands  of  the 
neck,  and  dropsy, — phenomena  which  are  not  encountered  in  the 
other.  It  is  true  that  in  very  rare  instances  of  diphtheria  we  en- 
counter a  slight  erythema  of  the  neck  and  breast,  but  it  is  not  like 
the  vivid,  diffused  rash  of  scarlet  fever.  Moreover,  the  exudation 
in  the  throat  is  not  exactly  similar  in  the  two  diseases.  In  scar- 
latina it  is  pultaceous,  and  not  coherent,  and  has  no  tendency  to 
spread  to  the  respiratory  passages.  Then  the  albuminuria,  the 
symptom  to  which  Wade  has  so  well  called  our  attention,  hap- 
pens at  a  different  period.  In  scarlatina  it  is  a  sequel  rather  than 
a  concomitant ;  in  diphtheria  it  is  a  concomitant  rather  than  a 
sequel.  Further,  the  gravity  of  the  symptom  is  not  the  same. 
In  the  latter  malady  it  is  an  indication  of  danger;  it  has  not  so 
serious  a  meaning  in  the  former. 

Diphtheria  may  be  intercurrent  in  various  maladies:  in  typhoid 
fever,  in  the  exanthemata,  in  pneumonia.  Nor  is  the  exudation 
always  restricted  to  the  throat.  It  may  show  itself  in  a  wound 
or  on  excoriated  skin,  on  the  nasal  mucous  membrane,  the  con- 
junctiva, the  nipple,  the  uvula,  or  around  the  anus;  it  may  be 
found  coating  the  stomach,  the  intestines,  and  the  ramifications 
of  the  bronchial  tubes. 

Nasal  diphtheria  is  a  very  grave  form  of  the  malady :  it  may 
either  be  present  alone,  or  coexist  with  a  deposit  in  the  fauces 
and  pharynx.  It  generally  occurs  with  evidences  of  the  septic 
form;  the  symptoms  are  of  a  low  type,  and  we  recognize  the 
affection  by  carefully  inspecting  the  posterior  pharynx  and  seeing 
that  the  membrane  extends  upward ;  by  noting  the  irritated,  red- 
dened look  of  the  nostril,  even  when  no  membrane  can  be  dis- 
cerned in  it ;  and  by  the  coryza,  the  sense  of  obstruction  in  the 
nose,  and  the  acrid  sanious  discharge  which  comes  from  it.  In 
cases  in  which  the  nasal  duct  and  the  laryngeal  canal  are  stopped 
up  by  the  false  membrane,  tears  are  constantly  rolling  down  the 
cheeks.  Epistaxis  is  a  not  uncommon  symptom  ;  swelling  of  the 
cervical  glands  may  or  may  not  be  present. 


DISEASES    OF    THE    MOUTH,    PHARYNX,    ETC.  435 

Chronic  Sore  Throat. — Attacks  of  angina  are  prone  to  re- 
cur, and  to  lead  to  chronic  inflammation  of  the  structures.  Now, 
an  affection  of  this  kind  is  liable,  on  any  exposure,  to  be  kindled 
into  the  acute  complaint;  besides,  it  yields  at  all  times  some 
manifestations  of  a  disorder  of  the  throat.  A  thickening  of  the 
folds  of  membrane  forming  the  half-arches,  a  tumefaction  of  the 
follicles  at  the  upper  part  of  the  pharynx,  a  lengthening  of  the 
uvula,  are  the  visible  signs  of  the  chronic  malady;  a  constant 
disposition  to  clear  the  throat,  and  a  dry  cough,  are  often  the 
attending  general  symptoms.  Owing  to  the  habitual  coughing, 
the  patient  may  be  suspected  to  be  laboring  under  phthisis,  and  be 
treated  accordingly,  when  the  whole  difficulty  lies  not  in  the  lungs, 
but  in  the  throat.  Yet  an  error  in  the  opposite  direction  is  quite 
as  easily,  and  perhaps  more  frequently,  committed.  It  is,  indeed, 
the  fashion  with  many  to  snip  off  tonsils  and  uvulas,  with  the 
view  of  curing  a  cough  which  is  really  kept  up  by  a  source  of 
irritation  in  the  lungs,  forgetting  that  in  scrofula  and  tuberculosis 
chronic  enlargement  of  the  tonsils  and  follicular  pharyngitis  are 
by  no  means  unusual.  A  careful  examination  of  the  chest  ought 
always  to  be  made,  even  when  inspection  of  the  throat  shows 
disease  to  be  there  present. 

The  follicular  disease  of  the  throat,  or  "  clergyman's  sore  throat," 
is  the  most  frequent  of  all  the  morbid  conditions  which  produce 
a  chronic  sore  throat.  As  Green,  who  so  well  described  the  dis- 
ease, pointed  out,  the  abnormal  condition  of  the  follicles  of  the 
mucous  membrane  of  the  pharynx  and  fauces  often  extends  to  the 
larynx.  There  are  constant  hawking  and  attempts  at  clearing  the 
throat,  and  not  unfrequently  roughness  of  voice  or  decided  hoarse- 
ness. On  inspecting  the  throat,  the  enlarged  mucous  follicles  can 
be  readily  discerned ;  those  on  the  pharynx  are  very  prominent. 
In  cases  of  long  standing,  the  follicles  may  ulcerate,  and  very 
commonly  they  pour  out  an  acrid  secretion.  But,  unless  from 
coexisting  enlargement  of  the  uvula  or  an  altered  position  of  the 
epiglottis,  or  marked  laryngeal  disease,  or  a  bronchial  complica- 
tion, there  is  no  decided  cough.  The  follicular  disease  may  occur 
in  consequence  of  repeated  attacks  of  sore  throat,  or  be  an  attend- 
ant upon  gastric  disorder,  or  follow  constant  exercise  and  straining 
of  the  voice. 

Ulcers  are  not  often  developed  in  the  fauces  during  an  attack 


136  MEDICAL    DIAGNOSIS. 

of  acute  inflammation,  except  in  the  specific  sore  throat  of  scar- 
latina; in  chronic  inflammation,  especially  if  occurring  in  scrofu- 
lous persons,  they  are  more  common.  The  most  profound  ulcer- 
ations are  those  of  constitutional  syphilis,  implicating,  as  they  do, 
not  only  the  tissues  of  the  fauces,  but  also  the  parts  in  front,  and 
destroying  both  the  fleshy  covering  of  the  bones  and  the  bones 
themselves.  With  regard  to  treatment  and  to  prognosis,  it  is  of 
the  utmost  importance  to  distinguish  these  syphilitic  ulcers  from 
those  produced  by  other  causes.  A  cutaneous  eruption  of  a  syphi- 
litic character,  and  enlarged  lymphatic  glands,  or  the  history  of 
antecedent  syphilis,  would  lead  us  to  a  correct  conclusion;  but  an 
accurate  history  of  a  syphilitic  infection  cannot  always  be  obtained. 
The  ulcers  themselves  furnish  some  information  by  which  we  may 
suspect  their  origin.  They  are  not  superficial  and  stationary,  like 
those  resulting  from  ordinary  inflammation  ;  on  the  contrary,  they 
are  deep,  and  have  a  strong  tendency  to  spread.  They  are  rounded, 
or  of  a  serpiginous  form,  with  borders  well  defined  and  elevated, 
and  surrounded  by  a  distinct  zone  of  redness ;  and  the  inflamma- 
tion which  precedes  them  is  limited  to  spots,  and  is  not  so  diffused, 
nor  attended  with  so  much  swelling,  as  the  inflammation  which 
exists  prior  to  simple  ulceration. 

PHARYNX   AND   (ESOPHAGUS. 

In  describing  the  affections  of  the  fauces,  those  of  that  portion 
of  the  pharynx  which  is  most  usually  the  seat  of  disease  have 
been  at  the  same  time  described.  Indeed,  when  we  speak  of 
acute  or  chronic  pharyngitis,  we  generally  mean  acute  or  chronic 
inflammation  of  the  fauces,  to  which  the  upper  part  of  the  pharynx 
belongs.  Inflammation  of  the  portion  of  the  pharynx  which  is 
out  of  sight  when  the  tongue  is  depressed,  is  rare.  It  may  be 
presumed  to  exist  if  there  be  pain  and  an  impediment  in  the  act 
of  swallowing  when  the  food  arrives  opposite  the  top  of  the  larynx, 
while  the  respiration  remains  free  and  the  voice  unaffected.  Ab- 
scesses sometimes  form  between  the  textures  composing  the  phar- 
ynx, and  between  its  posterior  wall  and  the  cervical  vertebrae. 
These  retropharyngeal  abscesses  mostly  result  from  disease  of  the 
vertebra?.  They  occasion  great  difficulty  in  deglutition  and  in 
breathing;  an  altered  voice;  dull  pain  and  stiffness  in  the  neck; 


DISEASES    OF    THE    MOUTH,    PHARYNX,    ETC.  437 

external  swelling,  which  may  or  may  not  be  ©edematous;  and 
commonly  a  tumefaction  at  the  back  of  the  throat,  which  can  be 
seen,  or  which  at  least  can  be  felt  with  the  finger  pressed  against 
the  posterior  wall  of  the  pharynx.  On  account  of  the  obstructed 
respiration  and  the  changed  voice,  the  disease  is  liable  to  be  mis- 
taken for  laryngeal  complaints,  especially  for  croup.  Its  differ- 
ences have  been  enumerated  above.* 

The  oesophagus  is  not  often  the  seat  of  disease.  We  meet  with 
acute  inflammation  produced  by  swallowing  boiling  water  or  cor- 
rosive poisons,  especially  nitric  or  sulphuric  acid,  or  ammonia. 
The  symptoms  of  acute  oesophagitis  are  usually  mixed  up  with 
those  of  inflammation  of  the  pharynx,  or  of  the  stomach.  We 
may,  however,  infer  its  presence  if  difficulty  and  pain  in  deglutition 
exist  for  which  nothing  in  the  throat  accounts,  and  if  these  phe- 
nomena be  associated  with  hiccough  and  with  a  burning  sensation 
between  the  shoulders,  in  the  course  of  the  tube. 

Of  the  chronic  diseases  of  the  oesophagus,  stricture  is  the  most 
common.  The  narrowing  may  take  place  at  any  part  of  the  tube, 
and  results  from  preceding  inflammation  or  ulceration,  from  can- 
cerous degeneration  of  the  walls,  or  from  the  pressure  of  a  tumor, 
of  an  abscess,  or  of  an  aneurism;  sometimes  it  is  congenital.  The 
formidable  malady  manifests  itself  by  impediment  in  swallowing : 
even  liquid  food  cannot  pass  without  great  difficulty ;  and  if  the 
stricture  go  on  increasing,  the  patient  perishes  miserably  by  star- 
vation. In  addition  to  the  obstruction  to  the  passage  of  food,  we 
may  find  a  peculiar  pain  occurring  at  a  particular  part  of  the  tube, 
and  that  the  patient  raises,  without  cough  or  vomiting,  clots  of 
blood  presenting  the  same  shape. 

The  matter  ejected  in  the  attempts  at  deglutition  consists  simply 
of  masticated  food  together  with  more  or  less  mucus.  If  long 
retained,  the  albuminous  materials  are  macerated  or  putrid;  the 
starchy  materials  are  in  process  of  fermentation;  fungi  are  also 
formed  in  great  quantities,  although  never  sarcinse.t  Should 
there  be  doubt  as  to  the  seat  of  the  obstruction,  a  bougie  will  clear 
up  the  doubt;  and  thus  we  possess  in  this  instrument  the  most 

*  See  an  elaborate  paper  on  the  subject  of  these  abscesses,  by  Allin,  New 
York  Journ.  of  Med.,  Nov.  1851 ;  also  Stephen  Smith,  Amer.  Journ.  of  the 
Med.  Sciences,  Oct.  1871 ;  Despres,  Gazette  des  Hopitaux,  No.  32,  1873. 

f  Ziemssen,  "Diseases  of  the  Oesophagus/'  in  Ziemssen's  Cyclopaedia. 


438  MEDICAL    DIAGNOSIS. 

valuable  diagnostic  as  well  as  therapeutic  agent.  But  we  must 
not  immediately  conclude,  because  the  bougie  meets  with  resist- 
ance, that  an  organic  stricture  is  present.  The  narrowing  may  be 
only  spasmodic,  yet  give  rise  to  the  symptoms  of  organic  con- 
striction. But  they  are  not  permanent:  at  times  nourishment  is 
readily  swallowed,  and  a  full-sized  bougie  passes  with  ease.  Spas- 
modic stricture  occasionally  accompanies  ulceration  of  the  larynx  ; 
but  it  is  chiefly  met  with  in  hypochondriacs  and  in  hysterical 
women.  The  latter,  indeed,  sometimes  fancy  that  they  are  incapa- 
ble of  swallowing,  and  reject  the  food  they  take  without  there 
being  even  a  temporary  spasm  to  prevent  its  passage. 

The  distinction  of  the  other  causes  of  stricture  is  not  always 
an  easy  matter.  In  the  stenosis  arising  from  syphilis,  we  lay 
great  stress  on  the  history  and  on  the  results  of  an  antisyphilitic 
treatment.  In  the  strictures  due  to  compression,  we  discern  the 
swelling  that  has  occasioned  them,  and  the  oesophagus  is  apt  to  be 
pushed  to  one  side.  In  strictures  the  result  of  cicatrices,  we  have 
the  gradual  development  of  the  affection  after  an  injury  or  the 
swallowing  of  some  irritant  poison,  and  the  great  resistance  of  the 
dense  tissues  to  the  sound  is  very  significant.  Cancerous  narrow- 
ing occurs  after  forty  years  of  age,  progresses  steadily,  and,  as 
Ziemssen  has  pointed  out,  is  frequently  associated  with  paralysis 
of  the  recurrent  laryngeal  nerves. 

Dilatation  of  the  oesophagus  above  the  seat  of  a  stricture,  or 
without  a  stricture  existing,  is  on  the  whole  a  rare  disease.  Its 
chief  symptoms,  when  extensive,  are  difficulty  in  swallowing, 
vomiting  or  regurgitation  of  food,  a  swelling  in  the  neck  coming 
on  after  eating  and  diminishing  greatly  after  vomiting  or  by 
pressure,  slowly  progressing  inanition,  and  at  times  long  spells 
of  delusive  improvement.  The  sound  may  penetrate  through  the 
neck  of  the  sac  with  difficulty,  or  enter  it  readily  ;  once  in  the 
sac,  the  end  of  the  tube  can  be  generally  moved  about  with  ease. 

In  all  the  diseases  mentioned,  the  value  of  the  sound  as  a 
means  of  diagnosis  has  been  spoken  of.  A  few  more  remarks 
about  it  may  not  be  amiss.  When  the  sound  on  reaching  a  par- 
ticular spot  always  occasions  pain  we  may  infer  the  existence  of 
inflammation  or  ulceration  at  this  point,  and,  in  the  case  of  ulcera- 
tion, some  pus  or  blood  is  likely  to  be  brought  up  on  the  instru- 
ment.     Should  any  doubt  exist  whether  the  sound  have  passed 


DISEASES    OF    THE    MOUTH,    PHARYNX,    ETC.  439 

into  the  oesophagus  or  into  the  larynx,  let  the  patient  be  directed 
to  speak ;  he  can  make  no  noise  if  the  tube  be  in  the  larynx.  In 
cases  remaining  doubtful,  a  lighted  candle  may  be  placed  before 
the  end  of  the  tube  projecting  from  the  mouth.  If  the  instru- 
ment be  in  the  windpipe,  the  flame  will  be  wafted  to  and  fro  with 
the  currents  of  air;  if  in  the  oesophagus,  nothing  of  the  kind  is  to 
be  observed,  except  when  the  tube  is  in  the  intrathoracic  portion. 

It  has  been  proposed  to  study  the  diseases  of  the  oesophagus  by 
means  of  auscultation,  listening  while  the  patient  swallows  food 
or  liquid;  and  we  owe  to  Hamburger  an  elaborate  description 
of  the  sounds.*  In  health,  the  oesophageal  sound  is  extremely 
distinct,  but  of  very  short  duration.  "We  should  distinguish  it 
from  the  pharyngeal  swallowing  sound,  which  is  generally  a  loud 
gurgle.  In  a  moderately  advanced  stage  of  stricture  of  the 
oesophagus,  a  noise  similar  to  emptying  a  bottle,  "clucking," 
"gurgling,"  is  perceived;  while  in  cases  of  dilatation  we  are  apt 
to  meet  with  a  sound  like  that  heard  when  rain  driven  by  the 
wind  impinges  and  is  deflected.  In  cases  of  very  marked  stricture 
or  of  obstruction  by  an  impacted  foreign  body,  we  find  that  the 
act  of  deglutition  cannot  be  detected  below  a  certain  point,  while 
it  is  distinct  above.  To  auscult  the  oesophagus,  we  should  place 
the  stethoscope  in  the  vicinity  of  the  hyoid  bone,  also  to  the  left 
of  the  vertebral  column  from  the  upper  dorsal  vertebra  downward. 
Whether,  however,  this  method  of  exploration  be  really  of  much 
value  is  unsettled. 

The  disorders  of  the  pharynx  and  oesophagus  have  as  a  common 
symptom  difficulty  in  swallowing.  But  we  must  not  forget  that 
other  causes  may  produce  dysphagia,  such  as  paralysis  of  the  mus- 
cles of  the  throat,  diseases  of  the  larynx  or  trachea,  particularly 
ulcerative  diseases,  and  aneurismal  tumors  within  the  chest. 

*  Jahrbiicher  der  k.  k.  Gesellschaft  der  Aerzte  in  "Wien,  Bd.  xviii.  See, 
also,  Oppolzer's  Lectures ;  Morell  Mackenzie,  London  Lancet,  May,  1874 ; 
AUbutt,  Brit.  Med.  Journ.,  Oct.  1875;  Gaston  Saint-Marie,  Des  differentes 
modes  d'exploration  de  l'oesophage,  Paris,  1875. 


CHAPTER  VI. 

DISEASES   OF   THE   ABDOMEN. 

The  abdominal  cavity  contains  viscera  of  very  varied  func- 
tions:  some  form,  others  break  down  organic  constituents;  while 
others,  again,  excrete  the  broken-down  material.  They  all,  how- 
ever, labor  in  one  cause ;  they  all  work  toward  preserving  a  nor- 
mal state  of  the  blood,  either  by  preparing  fit  matter  for  it,  and 
consequently  for  the  healthy  nutrition  of  the  frame,  or  by  re- 
moving such  substances  as  would  be  hurtful  if  they  were  retained. 
Any  serious  derangement  of  any  of  these  viscera,  especially  any 
serious  chronic  derangement  of  those  which  are  not  simply  reser- 
voirs, must  therefore  lead  to  a  deterioration  of  the  blood  and  to  a 
defective  nourishment  of  the  body.  But,  independently  of  the 
change  in  the  blood  and  the  falling  off  in  the  general  nutrition, 
there  are  no  vital  symptoms  which  characterize  abdominal  dis- 
eases as  a  group;  and,  as  many  other  causes  may  give  rise  to 
the  same  symptoms,  they  furnish  on  the  whole  but  little  infor- 
mation of  real  value  in  diagnosis,  none  at  all  as  to  the  particular 
organ  at  fault.  This  we  learn  to  some  extent  by  examining, 
where  it  can  be  done,  the  secretions  or  excretions ;  to  some  extent 
by  noticing  the  peculiar  appearances  of  the  skin  which  are  pro- 
duced by  deterioration  of  the  blood,  or  by  substances,  such  as  bile, 
circulating  in  it;  and  perhaps  to  a  still  greater  extent  by  the  ex- 
ploration of  the  organs  through  the  parietes  of  the  abdomen.  It 
is,  in  truth,  by  means  of  the  physical  method  of  investigation  that 
we  often  obtain  the  most  valuable  information  not  only  as  to  the 
seat  but  even  as  to  the  nature  of  the  morbid  action ;  and,  although 
physical  exploration  of  the  abdomen  does  not  yield  as  perfect  re- 
sults as  when  this  form  of  diagnosis  is  applied  to  the  affections  of 
the  thorax,  the  senses  of  sight  and  touch  still  supply  us  with  an 
amount  of  knowledge  most  valuable,  and  with  which  it  would  be 
difficult  to  dispense.  I  speak  only  of  the  senses  of  sight  and  touch, 
440 


DISEASES    OF    THE    ABDOMEN.  441 

because  the  sense  of  hearing,  save  in  so  far  as  it  enables  us  to 
judge  of  the  sounds  elicited  by  percussion,  or  of  murmurs  in  the 
vessels,  is  not  very  applicable  to  the  study  of  diseases  below  the 
diaphragm.  But  let  us  pass  in  review  the  different  methods  of 
physical  diagnosis  with  reference  to  abdominal  disorders. 

Methods  and  General  Kesults  of  Physical  Examination 
of  the  Abdomen, 

INSPECTION. 

By  inspection  we  learn  the  size,  shape,  form,  and  movements 
of  the  abdomen.  To  inspect  the  abdomen  satisfactorily,  the 
patient  should  be  placed  in  an  easy  attitude,  either  standing  or 
sitting.  The  recumbent  position  is  less  eligible,  yet  we  are  often 
obliged  to  examine  sick  persons  in  this  posture.  Whenever  prac- 
ticable, ocular  inspection  must  be  made  not  only  from  the  front, 
but  also  from  the  sides  and  from  the  back.  In  appreciating  the 
results  thus  obtained,  it  is  necessary  to  bear  in  mind  that  even  in 
health  the  appearance  of  the  abdominal  walls  is  modified  by  cer- 
tain physiological  conditions.  The  abdomen  is  much  larger,  in 
comparison  to  the  size  of  the  chest,  in  childhood  than  in  adult  age. 
It  is  more  voluminous  in  females,  especially  such  as  have  given 
birth  to  children.  It  increases  in  size  with  advancing  years,  par- 
ticularly when  a  tendency  to  obesity  exists.  Its  shape  is  somewhat 
altered  by  the  pernicious  habit  of  wearing  tight  stays.  Its  upper 
portion  is  distended  after  a  copious  meal. 

In  disease  we  may  observe  either  partial  or  general  abdominal 
enlargement  The  latter  is  caused  by  accumulations  of  air  in  the 
intestinal  canal ;  by  liquid  in  the  peritoneum ;  by  an  cedematous 
condition  of  the  abdominal  walls ;  or  by  large  tumors  which  fill 
up  the  whole  cavity.  A  partial  enlargement  is  mainly  produced 
by  an  increase  in  size  of  particular  organs,  such  as  of  the  liver, 
or  spleen,  or  ovaries.  It  may  also  be  brought  about  by  swelling 
of  the  mesenteric  glands,  or  by  tumors, — solid  or  hernial ;  and  it 
is  sometimes  due  to  diseases  above  the  diaphragm.  A  pleuritic 
or  a  pericardial  effusion,  or  emphysema  of  the  lungs,  may  give  rise 
to  a  marked  fulness  below  the  margin  of  the  ribs. 

A  retraction  of  the  abdominal  parietes  is  perceived  in  general 
emaciation,  and  is  very  obvious  in  that  dependent  upon  a  nar- 


442  MEDICAL    DIAGNOSIS. 

rowing  of  the  cardiac  or  pyloric  orifice  of  the  stomach,  or  upon 
chronic  diarrhoea  or  dysentery.  It  is  also  noticed  in  lead  colic 
and  in  cephalic  diseases,  especially  in  tubercular  meningitis. 

There  are  further  changes  in  the  appearance  of  certain  external 
parts  which  tend  to  elucidate  the  state  of  the  parts  within.  Thus, 
we  learn  from  the  distention  of  the  superficial  veins  that  an  ob- 
struction to  the  flow  of  blood  exists  in  the  large  veins  of  the  ab- 
domen, either  in  the  portal  system  or  in  the  vena  cava.  The  less- 
ening of  the  depression  at  the  umbilicus,  unless  it  be  produced 
by  pressure  limited  to  the  spot  where  the  umbilicus  lies,  is  a  sign 
indicative  of  general  abdominal  enlargement. 

"While  inspecting  the  abdomen,  we  may  see  distinct  movements. 
The  act  of  breathing  gives  rise  to  a  motion  which  is  very  slight 
when  a  tumor  or  any  other  impediment  interferes  with  the  free 
action  of  the  diaphragm,  and  which  is  much  exaggerated  by  dis- 
eases within  the  thoracic  cavity.  The  rolling  of  the  intestines  is 
sometimes  visible  on  the  exterior;  so  are  at  times  those  shiftings 
of  accumulations  of  gas  which  give  rise  to  a  series  of  jerking  ele- 
vations ;  so,  too,  are  occasionally  the  spasmodic  contractions  and 
relaxations  of  the  abdominal  muscles.  But  none  of  these  is  as 
frequently  encountered,  and  none  occasions  as  much  alarm,  as  a  pul- 
sation, the  chief  seat  of  which  is  the  epigastric  region,  and  which, 
as  we  shall  presently  see,  is  often  mistaken  for  an  aneurism. 

PALPATION. 

Palpation  teaches  us  important  lessons.  "We  judge  by  the  ap- 
plication of  the  hand  of  the  size,  position,  and  consistence  of  the 
viscera  which  are  felt  through  the  abdominal  walls.  We  deter- 
mine whether  the  parts  are  firmly  attached  or  movable ;  whether 
they  are  smooth  or  nodulated ;  whether  or  not  they  possess  a  mo- 
tion of  their  own.  We  ascertain  whether  they  are  tender  or  not; 
and  by  tapping  with  the  fingers  of  one  hand,  while  those  of  the 
other  are  applied  to  another  portion  of  the  surface,  we  discover, 
by  the  peculiar  feeling  of  fluctuation,  the  presence  of  fluid  in  the 
abdominal  cavity.  We  satisfy  ourselves  further,  by  the  sense  of 
touch,  of  the  state  of  the  parietes,  whether  hot  or  cold,  resistant  or 
elastic,  oedematous  or  not ;  and  we  may  detect  a  friction  fremitus. 

In  order  to  use  palpation  with  most  effect,  the  abdominal 
muscles  must  be  relaxed,  and  to  do  this  the  patient  should  be 


DISEASES    OF    THE    ABDOMEN.  443 

placed  on  his  back,  and  his  thighs  be  flexed  on  the  body.  Occa- 
sionally it  is  essential  to  vary  this  position ;  to  turn  him  from  side 
to  side,  or  to  examine  him  when  erect.  The  amount  of  pressure, 
too,  should  not  always  be  the  same.  When  we  wish  to  examine 
deep  parts,  the  pressure  is  increased ;  when  it  causes  pain,  the 
exploration  must  not  be  unnecessarily  repeated.  The  character 
and  the  intensity  of  the  pain  which  pressure  calls  forth  often 
throw  considerable  light  on  the  disease  we  are  investigating. 
Thus,  if  it  take  deep  pressure  to  produce  pain,  we  are  usually 
right  in  concluding  that  the  mischief  is  not  superficially  seated. 
The  pain  of  inflammation  of  the  serous  membrane  is  commonly 
much  augmented  by  pressure,  and  is  of  a  very  severe,  cutting 
character.  Pain  due  to  inflammation  of  any  part  of  the  mucous 
membrane  of  the  intestinal  tract  is  duller.  All  neuralgic  or  ner- 
vous pain,  such  as  that  of  colic,  is  relieved  rather  than  augmented 
by  pressure,  and  may  thus  be  distinguished  from  the  tenderness 
caused  by  inflammation.  Yet  this  is  to  be  regarded  as  a  rule 
which  has  many  exceptions. 

But  we  cannot  enter  into  any  fuller  particulars  as  to  what  pal- 
pation teaches  us  in  individual  diseases  of  the  abdomen ;  because, 
as  there  is  hardly  one  of  any  importance  in  which  it  is  not  of 
some  service,  we  should  say  here  what  it  would  be  necessary  to 
dwell  on  repeatedly  hereafter.  There  is,  however,  one  point  con- 
nected with  the  subject  which  may  be  briefly  alluded  to, — the 
attempt  to  use  palpation  as  a  means  of  diagnosis  by  the  introduc- 
tion of  the  hand  into  the  rectum.  This  method  has  been  recom- 
mended by  Simon,  and  it  is  claimed  that  the  hand  can  be  passed 
far  enough  to  detect  even  calculi  lodged  in  the  kidney.  But  the 
method  is  still  on  trial,  and  is  both  disagreeable  and  not  free  from 
danger.  Dilatation  of  the  sphincter  should  be  gradual,  five  min- 
utes at  least  being  allowed  for  its  accomplishment.  And  with  all 
precautions  the  information  obtained  may  be  indecisive.  Strictures 
high  up  in  the  rectum  or  in  the  sigmoid  flexure  of  the  colon  may 
be  readily  discerned,  but  a  stricture  below  the  descending  colon 
may  exist  although  the  hand  be  unable  to  discover  it. 

PEECTTSSIOlSr. 

Percussion  is,  in  the  study  of  abdominal  affections,  as  valuable 
as,  perhaps  even  more  valuable  than,  palpation.     By  it  we  can 


444  MEDICAL    DIAGNOSIS. 

circumscribe  the  different  organs  with  accuracy ;  we  can  judge 
of  the  position  of  the  stomach  and  intestines;  we  can  limit  the 
distended  bladder,  and  fix  the  borders  of  the  liver  and  spleen. 
By  its  aid,  further,  we  tell  whether  a  distention  of  the  abdomen  is 
produced  by  air,  or  by  a  solid  tumor,  or  by  liquid.  But,  without 
entering  here  into  any  particulars  as  to  its  use  in  the  recognition 
of  individual  abdominal  disorders,  we  may  examine  the  results  it 
yields  when  applied  to  the  healthy  abdomen. 

To  render  percussion  a  trustworthy  interpreter  of  the  state  of 
the  abdominal  viscera,  the  patient  should  be  placed  in  the  same 
position  as  for  palpation.  The  sounds  are  best  elicited  by  mediate 
percussion,  and  especially  by  mediate  percussion  performed  by 
means  of  a  pleximeter.  But,  to  appreciate  them  fully,  something 
more  is  requisite  than  to  produce  a  distinct  sound  and  to  be  able 
to  tell  whether  it  is  dull  or  tympanitic.  We  must  be  acquainted 
with  the  relations  of  the  parts  which  the  abdominal  walls  conceal 
from  view;  and  we  must  take  into  account  that  during  the  di- 
gestive process  the  contents  and  position  of  these  organs  may  vary 
sufficiently  to  modify  the  percussion  sound. 

To  begin  with  the  airless  viscera.  The  liver  is  one  of  the  easiest 
organs  to  limit.  AVe  determine  its  upper  boundary  by  striking 
with  moderate  force  in  a  line  from  somewhat  above  the  right 
nipple  toward  the  lower  part  of  the  thorax,  until  marked  resist- 
ance and  dulness  tell  us  that  a  solid  organ  has  been  reached.  At 
this  point  we  make  a  mark ;  then  we  again  percuss  downward 
from  near  the  median  line,  and  above  the  dulness  just  obtained; 
then  we  percuss  from  the  axilla  downward ;  then  posteriorly  from 
beneath  the  lower  angle  of  the  scapula ;  and  so  on,  until  the  line 
traced  out  reaches  the  vertebral  column. 

The  dulness  thus  elicited  marks  the  upper  boundary  of  the 
liver;  at  least  of  the  portion  more  directly  in  contact  with  the  ab- 
dominal walls.  Anteriorly  it  extends  from  the  lower  extremity 
of  the  sternum  to  between  the  fifth  and  sixth  ribs;  at  the  side, 
the  dulness  is  generally  in  the  seventh  intercostal  space;  near 
the  vertebral  column,  it  is  on  a  level  with  the  tenth  or  the 
eleventh,  more  rarely  with  the  ninth,  interspace.  The  dulness 
of  the  left  lobe  reaches  nearly  two  inches  across  the  median  line; 
but  the  heart  lies  here  so  near  to  the  liver  that  we  cannot  with 
accuracy  distinguish  the  flat  sound  of  the  one  from  the  flat  sound 


DISEASES    OF    THE    ABDOMEN.  445 

of  the  other;  nor  indeed  is  this,  for  practical  purposes,  of  great 
consequence. 

After  the  upper  border  has  been  fairly  traced  out  anteriorly, 
laterally,  and,  if  thought  necessary,  posteriorly,  we  determine 
the  inferior  margin  of  the  organ.  This  is  readily  effected  by 
percussing  downward  from  the  already  ascertained  line  of  duhiess, 
and  noting  where  the  large  intestine  sends  forth  its  distinct  tym- 
panitic sound.  To  determine  the  lower  border  correctly,  the  plex- 
imeter  must  be  pressed  firmly  on  the  integuments,  and  the  stroke 
of  the  finger  be  slight ;  for  if  it  be  strong,  we  obtain  the  sound  of 
the  surrounding  hollow  viscera  through  the  thin  layer  of  liver 
which  covers  them,  and  before  we  have  arrived  at  its  margin. 
This  mode  of  procedure  is  different  from  the  one  pursued  to  de- 
termine the  height  to  which  the  liver  rises,  because  the  position  of 
the  parts  is  different.  Superiorly,  the  lung  descends  between  the 
surface  and  that  portion  of  the  convex  surface  of  the  liver  which 
fits  into  the  diaphragm,  and  it  requires  strong  percussion  to  bring 
out  the  dulness  of  the  deep-seated  solid  organ.  By  forcible  per- 
cussion, however,  we  detect  a  decided  loss  of  the  pulmonary  reso- 
nance at  about  the  fourth  intercostal  space. 

The  inferior  border  of  the  liver  will,  anteriorly,  be  generally 
found  to  lie  immediately  at,  or  to  project  below,  the  last  rib ;  pos- 
teriorly, we  cannot  determine  this  border  positively,  for  it  becomes 
continuous  with  the  dulness  occasioned  by  the  right  kidney.  The 
lower  margin  of  the  left  lobe  is  commonly  met  with  at  the  upper 
third  of  a  line  drawn  from  the  ensiform  cartilage  to  the  umbilicus. 
A  distended  gall-bladder  may  cause  a  strictly  defined,  dulness 
lower  than  the  dulness  of  the  surrounding  liver. 

The  spleen  is  not  so  easily  circumscribed  as  the  liver.  Indeed, 
if  the  stomach  contain  much  food,  or  if  it  or  the  intestines  be  dis- 
tended with  gas,  it  is  very  difficult  to  discriminate  the  dull  sound 
of  the  spleen.  To  find  its  limits,  we  must  place  the  patient  on 
his  right  side,  with  his  legs  flexed;  or  let  him  stand  erect,  and 
then  begin  to  strike  with  some  force  in  a  line  from  the  axilla  to 
the  crest  of  the  ilium.  At  the  ninth,  or  sometimes  at  the  tenth, 
rib,  the  sound  becomes  dull,  and  there  is  much  greater  resistance 
to  the  finger.  Here  is  the  upper  boundary  of  the  spleen.  We 
mark  the  spot,  and  continue  to  percuss  in  the  same  line  until, 
at  about  the  twelfth  rib,  we  arrive  at  the  lower  boundary  of 


446  MEDICAL    DIAGNOSIS. 

the  organ,  .as  indicated  by  the  distinct  tympanitic  sound  of  the 
intestines. 

After  the  vertical  diameter  has  been  thus  ascertained,  the  hori- 
zontal is  readily  determined  by  percussing  from  the  median  line 
to  a  point  between  the  lines  which  trace  the  superior  and  inferior 
margins,  and  by  noticing  where  the  sound  of  the  stomach  gives 
way  to  the  dull  sound  of  the  solid  viscus.  When  these  three 
points  have  been  decided  upon,  we  have  learned  enough  for  prac- 
tical purposes.  We  may  then,  if  we  choose,  percuss  posteriorly ; 
but  we  cannot  circumscribe  the  spleen  with  any  accuracy  behind, 
because  its  dulness  becomes  continuous  with  that  of  the  left  kidney. 

The  average  size  of  the  spleen  is  four  inches  in  length  and  three 
in  width ;  but  it  may  in  a  diseased  state  increase  to  twice  or  three 
times  that  size.  When  the  viscus  eludes  detection  by  percussion 
we  may  infer  it  to  be  small;  provided  the  stomach  and  intestines 
be  not  much  distended  with  gas. 

The  kidneys  cannot  be  limited  with  anything  like  accuracy,  ex- 
cept at  their  inferior  and  outer  borders,  where  the  dull  sound  they 
occasion  is  surrounded  by  the  intestinal  resonance.  This  dulness 
extends  somewhat  lower  during  a  full  inspiration. 

To  set  limits  to  the  stomach  and  intestines,  by  means  of  percus- 
sion, requires  an  ear  accustomed  to  discriminate  between  shades  of 
sound,  since  we  have  to  judge  more  between  sounds  of  different 
degree,  but  similar  to  one  another,  than  between  sounds  of  different 
character.  Nor  are  the  tones  elicited  always  the  same  over  the 
same  spot ;  they  vary  as  the  contents  of  the  hollow  viscera  vary. 
We  can  make  use  of  this  circumstance  for  purposes  of  diagnosis. 

The  stomach,  when  not  unusually  distended  with  gas  or  with 
food,  renders  a  sound  which  is  hollow,  ringing,  and  tympanitic  to 
a  certain  degree,  yet  which  is  not  tympanitic  as  that  of  the  intes- 
tine is.  It  is  in  fact  a  sound  unlike  any  other,  and  experience 
soon  enables  us  to  distinguish  it  from  that  of  the  surrounding 
viscera.     Sometimes  the  sound  is  distinctly  amphoric. 

Now,  to  determine  the  boundaries  of  the  stomach,  it  is  necessary 
to  mark  out  first  the  lower  margin  of  the  liver,  for  it  covers  a 
portion  of  the  stomach ;  then  the  heart  and  the  inner  border  of 
the  spleen.  The  part  which  lies  between  these  solid  viscera  yields 
the  sound  of  the  stomach,  mixed  at  one  point,  namely,  to  the  left 
of  the  apex  of  the  heart,  with  the  resonance  of  the  lung.     Near 


DISEASES    OE    THE    ABDOMEN. 


447 


this  spot,  about  opposite  to  the  seventh  rib,  the  cardiac  extremity 
of  the  stomach  is  situated ;  below  it  is  the  body  of  the  organ.  To 
ascertain  its  lower  border,  we  percuss  gently  in  a  downward  direc- 
tion, until  the  alteration  in  sound  shows  that  we  are  striking  over 


Fig.  39. 


Besults  of  abdominal  percussion,  as  set  forth  in  the  text.  The  dark  shades  indi- 
cate marked  dulness;  the  light  shading  exhibits  a  lessening  of  the  clear  or  of  the 
tympanitic  character  of  the  sound, — an  approach  to  dulness. 


the  colon.  The  difference  is  at  times  very  obvious,  at  times  very 
slight.  It  is  readily  detected  if  the  stomach  contain  either  solid 
or  liquid  ingesta.  Availing  ourselves  of  this  fact,  we  may  some- 
times follow,  with  advantage,  Mailliot's  advice,  and  let  the  patient 
swallow  a  glass  of  water.  By  placing  him  in  the  erect  position, 
the  fluid  gravitates  to  the  greater  curvature,  and  the  line  of  com- 
parative dulness  indicates  the  lower  margin  of  the  stomach,  which 
is  generally  found  near  the  umbilicus. 


448  MEDICAL    DIAGNOSIS. 

Another  method  to  determine  the  limits  of  the  organ,  as  well  as 
whether  or  not  the  pylorus  is  capable  still  of  self-closure  in  the 
direction  of  the  duodenum,  or  is  permanently  patent,  has  been 
recently  proposed  by  Ebstein.*  It  consists  in  the  distention  of 
the  stomach  by  means  of  carbonic  acid,  generated  by  first  letting 
the  patient  swallow  tartaric  acid  dissolved  in  lukewarm  water  and 
then  rather  more  bicarbonate  of  sodium,  about  a  full  teaspoonful. 
The  stomach  becomes  very  much  distended,  and  emits  a  deep 
tympanitic  note  on  percussion,  unlike  that  over  the  intestines; 
but  if  the  pylorus  be  incapable  of  closure,  the  intestines  too  become 
swollen,  and  their  tympanitic  note  is  changed. 

The  colon  yields,  in  its  ascending  and  transverse  as  well  as  in  its 
descending  portion,  a  sound  of  a  purer  tympanitic  character  than 
the  stomach,  the  note  of  which  is,  indeed,  in  many  respects  more 
amphoric  than  tympanitic.  When,  however,  the  tube  contains 
fseces, the  sound  is  modified;  and  as  these  are  prone  to  accumulate 
on  the  left  side  in  the  descending  colon,  and  especially  where  this 
passes  into  the  iliac  fossa,  it  is  usually  not  so  resonant  as  the 
ascending  colon.  The  small  intestines,  unless  they  are  filled  with 
fluid  or  solids,  or  distended  with  gas,  render  a  sound  of  higher 
pitch  and  of  smaller  volume  than  the  surrounding  large  intestine, 
and  by  the  less  deep-toned  sound  their  position  may  be  accurately 
determined. 

The  position  of  the  viscera  in  the  pelvis  cannot  be  ascertained 
by  means  of  percussion.  It  is  only  when  the  bladder  is-  much 
distended,  or  the  uterus  augmented  in  size,  that  the  outline  of 
either  can  be  traced  on  the  walls  of  the  abdomen. 

AUSCULTATION. 

Auscultation  is  serviceable  in  aiding  in  the  detection  of  an 
abdominal  aneurism;  and  sometimes  an  enlarged  spleen  gives  rise 
to  a  distinct  blowing  murmur;  or  the  rubbing  of  a  roughened 
peritoneum  may  occasion  a  friction  sound ;  but,  on  the  whole,  the 
application  of  the  stethoscope  to  the  abdominal  walls  is  rarely 
called  for.  In  health,  no  constant  sound  is  heard  save  that  of 
the  aorta;  for  the  rush  of  blood  through  the  other  arteries,  or 
through  the  veins,  produces  no  appreciable  murmur.     When  the 

*  Klinische  Vortrasre,  No.  155,  1878. 


DISEASES    OF    THE    STOMACH.  449 

stomach  is  distended  with  air  and  contains  liquid,  sounds  possessing 
a  metallic  character  are  perceived,  which  an  inexperienced  observer 
is  apt  to  consider  as  originating  in  the  lungs;  over  which,  in  truth, 
they  are  often  audible.  The  passage  of  gas  through  the  intestines 
gives  rise  to  those  peculiar  noises  termed  "  borborygmi."  In  the 
pregnant  state,  auscultation  is  of  value  in  detecting  the  pulsations 
of  the  foetal  heart  and  the  utero-placental  murmur. 


SECTION  I. 


DISEASES   OP  THE  STOMACH. 


As  the  disorders  of  the  stomach  are  so  common ;  as  we  are  so 
constantly  called  upon  to  remedy  them ;  as  a  patient  hardly  ever 
gives  a  history  of  his  ailment  without  thinking  it  obligatory  to 
enter  into  a  minute  account  of  the  state  of  his  digestion,  it  would 
be  reasonable  to  suppose  that  as  a  class  no  affections  are  so  well 
understood  and  so  susceptible  of  clear  description  as  those  of  this 
viscus.  But  in  point  of  fact  there  are  none  so  little  understood ; 
and  indeed  it  is  only  within  the  last  few  years  that  any  attempts 
have  been  made  to  penetrate,  with  the  light  thrown  by  modern 
means  of  research,  the  darkness  which  surrounds  the  pathology  of 
one  of  the  most  important  organs  in  the  body.  Most  of  these 
attempts  have  had  as  their  goal  to  ascertain  the  exact  anatomical 
changes  and  the  modifications  in  the  secretions  which  give  rise  to 
the  symptoms  commonly  referred  to  perverted  function ;  and  to  a 
certain  degree  they  have  been  successful ;  but  not  to  that  degree 
which  enables  us  to  associate  each  symptom  with  some  definite 
alteration  in  the  healthy  structure  or  in  the  normal  action  of  the 
part. 

The  symptoms  which  are  constantly  met  with  in  derangements 
of  the  stomach,  whether  organic  or  functional,  are  loss  of  appetite, 
nausea  and  vomiting,  acidity,  flatulency,  and  pain.  Before  in- 
quiring into  the  individual  diseases  of  the  viscus,  we  shall  briefly 
pass  these  symptoms  in  review. 

LOSS  of  Appetite. — This  is  one  of  the  most  common  signs  of 

29 


450  MEDICAL    DIAGNOSIS. 

a  disordered  stomach.  It  manifests  itself  in  various  ways.  It  may 
amount  to  absolute  repugnance  to  taking  any  kind  of  food,  or 
may  be  merely  an  inability  to  partake  of  certain  articles.  Again, 
little  by  little  the  process  of  digestion  may  become  more  and  more 
difficult  and  annoying,  and  the  patient  in  consequence  instinctively 
abstains  from  eating,  except  in  quantities  barely  sufficient  to  keep 
up  life.  What  the  loss  of  appetite  depends  on,  we  do  not  know ; 
nor  shall  we  until  the  causes  of  appetite  and  hunger  are  defini- 
tively settled.  That  nervous  influence  has  something  to  do  with 
the  anorexia,  is  shown  by  the  sudden  deprivation  of  all  desire  to 
eat  when  any  strong  impression  is  made  on  the  nervous  system, 
— such  as  that  caused  by  the  unexpected  receipt  of  unwelcome 
news.  The  collection  of  epithelium  on  the  mucous  membrane  is 
also  connected  with  a  marked  diminution  of  the  appetite;  for  with 
a  tongue  much  coated,  absolute  disgust  at  the  mere  thought  of 
taking  food  often  exists,  which  yields  to  relish  for  food  as  soon  as 
the  tongue  begins  to  clean. 

Attending  the  diminished  or  lost  appetite,  we  meet  sometimes 
with  great  emaciation  and  with  signs  as  if  even  the  small  quantity 
of  food  taken  were  not  absorbed  into,  or  utterly  failed  to  nourish, 
the  system.  Moreover,  there  is  apt  to  be  sensitiveness  over  the 
abdomen,  and  spots  of  particular  sensitiveness  exist  which  corre- 
spond to  the  situation  of  the  mesenteric  glands.  We  find,  how- 
ever, no  evidence  of  actual  organic  disease,  either  in  the  abdomen 
or  in  the  lungs ;  nor  does  this  pseudo-tabes  mesenterica,  if  I  may 
so  call  it,  occur,  like  the  disease  it  simulates,  in  scrofulous  or  tuber- 
cular patients.  I  have  met  with  a  number  of  cases,  chiefly  in  young 
women  with  lowered  vital  force,  fond  of  excitement,  and  living 
indolent  lives.  Some  were  hysterical,  others  not.  But  in  all  the 
complaint  seemed  to  be  due  to  deficient  nerve-power,  with  impaired 
function  of  the  stomach,  and  very  possibly  of  the  abdominal  glands. 
This  disorder  is  probably  the  same  as  that  described  by  Sir  Wil- 
liam Gull  as  hysteric  apepsia,*  and  kindred  to  the  affection  delin- 
eated by  Lasegue  as  hysteric  anorexia. f 

Instead  of  the  appetite  being  lost,  it  is  at  times  capricious,  or 
even  ravenous.     A  craving  after  food  is  not  often  combined  with 


*  Transactions  of  the  Clinical  Society,  vol.  vii.,  1874. 
f  Arch.  Gen.  de  Med.,  April,  1873. 


DISEASES    OF    THE    STOMACH.  451 

a  structural  lesion.  Yet  we  occasionally  meet  with  it  in  persons 
affected  with  gastric  ulcer.  It  is  common  to  find  it  in  those  who 
suffer  from  neuralgia  of  the  stomach.  And  sometimes  in  cases  of 
mere  nervous  gastric  disturbance,  with  or  without  pain,  there  is 
an  extraordinary  exaggeration  of  the  appetite:  the  patient  eats 
largely  eight  or  even  fifteen  times  a  day,  digests  his  food,  yet  is 
constantly  hungry.* 

The  feeling  of  thirst  does  not  lessen  when  the  desire  for  food  does. 
On  the  contrary,  it  usually  increases  when  the  latter  diminishes. 

Excessive  Acidity  of  the  Stomach. — Excessive  acidity 
occurs  from  various  causes.  The  gastric  juice  may  be  secreted  in 
great  quantities,  or  it  may  contain  an  abnormal  amount  of  acid. 
But  excessive  acidity  is  most  frequently  due  to  the  decomposition 
of  food  and  to  a  process  of  fermentation  dependent  rather  upon 
an  insufficient  amount  of  the  gastric  solvent  than  upon  its  super- 
fluity. It  then  manifests  itself  only  after  meals.  When  the  mu- 
cous membrane  is  covered  with  a  tenacious  mucus  or  with  thick 
layers  of  epithelium,  slow  digestion  and  acidity  from  fermentation 
result;  because,  although  the  gastric  juice  is  sufficient,  it  cannot 
mix  as  readily  with  the  aliment. 

The  acids  formed  in  the  stomach  are,  besides  the  muriatic  acid 
of  the  gastric  juice,  lactic  acid,  acetic  acid,  carbonic  acid,  butyric 
acid,  and  oxalic  acid.  Some  articles  of  food  produce  these  differ- 
ent acids  in  considerable  quantities.  Thus,  sugar  generates  large 
amounts  of  lactic  acid.  The  acids  which  are  created  in  the  stomach 
may  get  into  the  blood,  and,  by  vitiating  this  fluid,  give  rise  to 
various  disorders. 

When  much  acid  is  present  in  the  viscus,  it  occasions  a  sensa- 
tion of  heat  which  extends  along  the  oesophagus.  This  "  heart- 
burn" is  apt  to  happen  in  paroxysms,  and  is  attended  with  a 
feeling  of  constriction  or  with  actual  pain  at  the  epigastrium.  As 
a  symptom  it  has  no  special  diagnostic  value,  for  it  is  met  with 
both  in  functional  and  in  organic  diseases  of  the  stomach.  It 
simply  denotes  extreme  acidity;  and  it  is  very  common  in  gouty 
persons.  It  probably  arises,  as  Chambers  surmises,  from  the  ac- 
tion of  the  acid  contents  of  the  organ  on  the  oversensitive  nerves 
of  the  cardiac  end  and  of  the  oesophagus. 

*  Cases  recorded  by  Guipon,  Bulimic  and  Syncopal  Dyspepsia. 


452  MEDICAL    DIAGNOSIS. 

Flatulency. — The  gas  in  the  intestinal  canal  may  be  merely 
air  which  is  swallowed  j  or  it  may  be  generated  from  imperfectly 
digested  food ;  or  it  may  be  a  secretion  from  the  blood-vessels  of 
the  part.  In  those  who  suffer  from  indigestion,  it  is  produced 
in  the  last  two  ways,  and  the  patient  complains  greatly  of  the 
annovance  it  occasions.  It  causes  a  disgust  for  eating,  a  feeling 
of  distention,  and  sometimes  actual  pain.  By  interfering  with 
the  downward  movements  of  the  diaphragm,  it  induces  a  sensation 
of  constriction  in  the  chest,  shortened  breathing,  palpitation  of  the 
heart,  and  the  sleep  is  broken  by  uneasy  dreams. 

An  expulsion  of  the  gaseous  contents  of  the  stomach  by  the 
mouth  gives  rise  to  eructation,  or  belching.  The  belching  which 
follows  the  decomposition  of  food  has  sometimes  the  taste  and  the 
odor  of  rotten  eggs,  owing  to  the  gas  evolved  consisting  of  sul- 
phuretted hydrogen.  At  other  times  the  eructation  is  odorless, 
because  the  gases  formed  are  carbonic  acid,  or  hydrogen  or  nitro- 
gen, or  some  of  their  compounds.  "When  the  gas  results  from 
fermentation  or  decomposition  of  food,  it  frequently  coexists  with 
acidity  occurring  only  after  meals,  and  we  remedy  it  by  adminis- 
tering the  mineral  acids  or  agents  which  promote  digestion.  When 
it  is  a  secretion  from  the  blood-vessels,  it  happens  in  an  empty 
state  of  the  stomach,  and  is  often  relieved  by  simply  regulating 
the  time  of  taking  food,  so  as  to  avoid  too  long  intervals  between 
the  meals.  As  a  cause  of  flatulence  and  eructation  which  it  is 
important  not  to  overlook  may  be  mentioned  thoracic  aneurisai.* 

Nausea  and  Vomiting. — These  are  often  combined.  But 
sometimes  there  is  persistent  nausea  without  vomiting;  sometimes 
vomiting  occurs  without  any  or  with  but  slight  nausea.  Yet  they 
are  both  occasioned  in  much  the  same  way  :  what  gives  rise  to  one 
will  generally  give  rise  to  the  other. 

Vomiting  is  a  complex  act.  But  its  causes,  although  various, 
may  all  be  ranged  under  four  heads.  It  either  arises  from  an 
irritation  of  the  peripheral  extremities  of  the  nerves  which  sup- 
ply the  parts  more  directly  concerned  in  the  act  itself,  such  as  the 
stomach,  the  diaphragm,  and  the  oesophagus;  or  the  irritation 
originates  in  the  centres  from  which  these  nerves  spring,  and  is 
referred  to  their  peripheries ;  or  there  is  a  mechanical  obstruction 

*  Walter  F.  Atlee,  Amer.  Journ.  of  Med.  Sci.,  July,  1869. 


DISEASES    OF    THE    STOMACH.  453 

in  the  stomach  or  intestines ;  or  the  vomiting  is  purely  sympa- 
thetic. To  illustrate  these  different  forms  in  full  is  not  necessary. 
I  shall  merely  mention  a  few  examples  of  each.  Under  the  first 
head  belongs  the  vomiting  observed  in  acute  or  chronic  inflamma- 
tion of  the  stomach,  in  ulcer,  or  in  cancer;  also  that  following  a 
debauch,  or  the  introduction  of  irritating  substances  into  the  vis- 
cus.  Under  the  second  head  may  be  ranged  the  vomiting  which 
occurs  in  diseases  of  the  brain  ;  perhaps,  also,  that  which  arises  in 
morbid  states  of  the  blood,  in  Bright's  disease.  Under  the  third 
head  we  may  class  the  vomiting  in  narrowing  of  the  oesophagus 
and  of  the  pyloric  or  cardiac  extremity  of  the  stomach,  and  in 
obstructions  of.  the  intestine.  It  is,  however,  a  question  whether 
the  vomiting  in  all  these  cases  is  not  owing;  to  the  same  ultimate 
cause  as  that  of  the  first  group ;  whether,  in  other  words,  it  is  not 
a  reflex  phenomenon  called  forth  by  the  irritation  at  the  seat  of 
the  impediment. 

The  fourth  group  is  exemplified  by  the  vomiting  in  pregnancy, 
in  wounds  of  the  extremities,  in  inflammation  of  the  peritoneum, 
of  the  intestines,  and  of  the  liver,  in  renal  calculus,  and  in  irrita- 
tion of  the  fauces.  In  the  five  last  instances  the  vomiting  is  due 
to  direct  transmission  of  the  irritation,  and  must  be  looked  upon 
as  originating  through  means  of  that  sympathy  called  by  physiol- 
ogists continuous.  The  first  two  illustrate  the  remote  sympathy 
between  different  parts  of  the  body,  of  which  disease  often  furnishes 
such  striking  proofs. 

Connected  thus  with  so  many  various  conditions,  the  act  of 
vomiting,  taken  by  itself,  is  of  little  diagnostic  value.  It  pre- 
supposes a  certain  amount  of  irritation  existing  in  the  stomach, 
or  reflected  to  it ;  but  nothing  more.  It  is  of  course  a  frequent 
symptom  in  disorders  of  the  stomach,  especially  in  those  which  are 
organic;  yet  the  error  of  considering  it  as  having  reference  only 
to  derangements  of  that  viscus  ought  to  be  strenuously  guarded 
against.  As  it  is  allied  to  morbid  states  too  numerous  to  be  here 
examined  in  detail,  I  shall  content  myself  with  making  general 
statements  regarding  the  indications  to  be  drawn  from  it. 

When  vomiting  is  observed  in  a  person  previously  in  good 
health,  we  may  suspect  either  the  invasion  of  some  acute  malady, 
or  that  some  poisonous  substance  has  been  wilfully  or  acciden- 
tally taken.      Again,   it    may  come   on    suddenly  from  violent 


454  MEDICAL    DIAGNOSIS. 

mental  emotion.  When  everything  that  is  swallowed  is  imme- 
diately expelled,  the  difficulty  lies  in  the  oesophagus,  or  at  the 
cardiac  orifice  of  the  stomach,  or  in  an  extreme  irritability  of 
the  viscus;  and  this  irritability,  attended  as  it  often  is  with 
unceasing  nausea,  experience  teaches  to  be  more  frequently  due 
to  sympathetic  excitement  of  the  organ  than  to  structural  gastric 
disease. 

As  regards  the  vomiting  which  is  brought  about  by  gastric 
disorders,  it  is  of  much  consequence  to  note  the  period  at  which 
it  happens,  whether  before  meals  or  after  meals,  and  how  long 
afterward.  In  some  diseases,  such  as  ulcer  and  cancer,  it  rarely 
occurs  except  when  food  has  been  taken.  The  act  of  vomiting 
then  affords  relief  from  the  pain.  In  narrowing  of  the  pylorus,  it 
takes  place  some  hours  after  digestion  has  begun.  But,  as  vomit- 
ing will  be  described  hereafter  in  its  relations  to  the  individual 
diseases  of  the  stomach,  we  shall  not  anticipate  what  will  be  more 
fitly  discussed  elsewhere.  For  the  same  reason,  we  need  not  dwell 
on  the  characteristics  of  the  ejected  matter.  Yet  a  few  words  on 
the  subject  can  hardly  be  omitted. 

The  nature  and  the  quantity  of  the  vomit  are  of  course  most 
various.     The  following  are  its  most  common  kinds : 

Food  or  liquid,  mixed  with  saliva  and  some  mucus,  is  expelled 
when  the  stomach  is  very  irritable,  or  if  an  obstruction  exist 
which  renders  the  entrance  into  the  organ  difficult  or  impossible. 
Half-digested  food,  in  a  state  of  acetous  fermentation  and  with  a 
strongly  acid  reaction,  is  cast  out  when  the  proper  secretion  of  the 
gastric  juice  or  its  intimate  admixture  with  the  aliment  has  been 
interfered  with,  or  when  the  food  has  been  detained  for  a  long  time 
in  the  stomach.  This  kind  of  vomit  is  usual  in  chronic  inflam- 
mation and  in  cancer  of  the  stomach,  especially  in  the  latter.  In 
the  ejected  matter  the  particles  of  food  may  still  be  recognized 
with  the  unassisted  eye;  but  when  the  food  has  been  kept  for  a 
prolonged  period  in  the  stomach,  or  when  it  has  passed  on  into 
the  duodenum  and  is  returned,  it  is  changed  into  an  apparently 
homogeneous  mass.  Examined,  however,  under  the  microscope, 
the  different  elementary  structures  of  the  animal  or  vegetable 
substances  partaken  of  can  even  then  be  detected.  Mixed  with 
muscular  fibre,  fibrous  tissue,  starch-corpuscles,  and  vegetable  cells, 
is  usually  found  a  quantity  of  oil. 


DISEASES    OF    THE    STOMACH.  455 

Sarcince  and  yeast  fungi  are  sometimes  discovered,  by  means  of 
the  microscope,  in  the  vomit.  These  organisms,  first  described  by 
John  Goodsir,  are  the  result  of  a  process  of  fermentation,  and  are 
generally  associated  with  copious  vomiting.    They  are  small  square 

or  slightlv  oblong;  bodies,  divided  into 

•     m  n  ±-         I  r  Fig.  40. 

similar   smaller   portions   by  cross-lines, 

and  each  portion  thus  formed  is  again 

subdivided ;    but   the    markings   of  the 

smaller  squares  are  not  so  distinct  as  those 

of  the  larger.     The  illustration  shows  a 

mass  of  sarcinse  found  in  the  vomit  of  a 

.  SarcinK  ventriculi. 

patient  who  suffered  from  gastric  ulcer. 

Vomit  containing  sarcinse  is  always  indicative  of  structural 
change  in  the  stomach.  It  is  sometimes  found  in  chronic  gastritis 
of  long  standing;  or  in  connection  with  ulcer,  and  yet  oftener 
with  cancer,  and  especially  in  those  cases  in  which  the  narrowing 
at  the  pyloric  extremity  has  led  to  distention  of  the  organ.  In 
truth,  it  is  the  opinion  of  eminent  pathologists  that  the  presence 
of  sarcinse  requires  that  there  should  be  some  condition  which 
prevents  the  stomach  from  completely  emptying  itself. 

Sarcina  vomit  has  an  acid  smell  and  reaction,  and  often  a  pecu- 
liar brownish  appearance.  After  standing,  it  becomes  covered 
with  a  dirty,  frothy  matter,  like  yeast ;  but,  owing  to  the  amount 
of  half-digested  food  at  times  mixed  with  it,  its  aspect  is  not  uni- 
form, and  it  is  only  by  the  microscope  that  the  presence  of  the 
strange  bodies  can  be  recognized  with  certainty. 

The  process  of  fermentation  which  attends  the  development  of 
the  sarcinse  occasions  heart-burn  and  extreme  flatulency,  both  of 
which  add  greatly  to  the  distress  of  the  patient;  and  the  copious 
vomiting:  is  a  source  of  relief,  since  the  formation  of  acid  and  of 
wind  is,  for  the  time  being,  almost  entirely  or  wholly  arrested. 

Mucus  is  occasionally  ejected  in  large  quantities,  both  mixed 
with  food  and  pure.  In  chronic  gastritis,  and  in  the  milder  forms 
of  acute  gastritis,  the  mucous  membrane  is  covered  with  a  tena- 
cious  secretion,  and  a  considerable  amount  of  a  glairy  or  stringy 
matter  is  expelled  by  the  act  of  vomiting.  As  a  general  rule, 
indeed,  it  may  be  stated  that,  when  much  mucus  is  evacuated, 
an  inflammatory  condition  of  the  mucous  membrane,  or  what  is 
termed  a  catarrhal  state  of  the  stomach,  is  present. 


456  MEDICAL    DIAGNOSIS. 

A  thin,  watery  Jin  id,  looking  much  like  saliva,  is  discharged  in 
some  cases  of  organic  disease  of  the  stomach,  and  more  frequently 
still  in  functional  derangement  of  the  organ  brought  on  by  eating 
coarse  food.  Now  and  then  it  is  met  with  in  pregnancy.  This 
variety  of  vomiting  is  popularly  known  as  "water-brash  ;"  tech- 
nically, as  pyrosis.  It  may  be  attended  with  a  burning  sensation 
extending  to  the  fauces,  and  with  pain  running  back  to  the  spine. 
Generally  it  is  a  tractable  disorder  if  proper  food  be  taken.  The 
fluid  is  commonly  alkaline;  sometimes,  owing  to  its  intimate  ad- 
mixture with  the  gastric  contents,  it  is  acid. 

The  source  whence  the  fluid  is  derived  is  not  settled.  Frerichs 
found  that  it  possessed  the  power  of  converting  starch  into  sugar. 
On  this  account,  it  has  been  presumed  to  be  saliva,  which,  after 
having  accumulated  in  the  stomach,  induces  vomiting ;  or  saliva 
which  by  a  spasm  at  the  entrance  of  the  stomach  is  prevented 
from  entering  that  organ,  and  is  ejected  after  collecting  in  consid- 
erable quantities.  By  others  it  is  regarded  as  being  formed  by 
the  glands  at  the  lower  part  of  the  oesophagus.  It  was  for  a  long 
time  looked  upon  as  a  secretion  from  the  pancreas,  and  was  con- 
sidered a  sign  that  the  pancreas  was  diseased  and  not  performing 
its  function.     But  this  view  is  untenable. 

Bile  may  find  its  way  into  the  stomach,  and  be  expelled  by  the 
mouth,  imparting  to  the  vomit  a  greenish  or  yellowish  color  and 
a  very  bitter  taste.  The  occurrence  of  bilious  vomiting  is  com- 
monly held  to  indicate  a  disease  of  the  liver,  or  that  the  patient  is 
extremely  "  bilious."  It  is  not  a  proof  of  either.  It  is  observed 
when  there  is  much  retching,  and  when  the  act  of  vomiting  is 
protracted  and  frequently  repeated,  and  is  chiefly  met  with  in  the 
various  forms  of  acute  gastritis,  and  at  the  invasion  of  some  acute 
malady  which  gives  rise  to  sympathetic  disturbance  of  the  stomach. 

Fcecal  vomiting  never  depends  upon  a  disease  of  the  stomach. 
It  may  possibly  be  owing  to  a  fistulous  opening  between  the  colon 
and  the  stomach;  but  such  cases  are  extremely  rare.  Generally 
it  is  due  to  a  mechanical  obstruction  to  the  passage  of  faeces. 
Occasionally  it  happens  in  fevers  of  a  low  type,  or  in  peritonitis, 
and  is  then,  perhaps,  the  result  of  paralysis  of  a  portion  of  the 
intestinal  tube,  which  acts,  to  some  extent,  as  a  mechanical  ob- 
struction. The  matter  that  is  ejected  has  the  odor  of  faeces;  but 
it  is  commonly  of  less  firm  consistence,  and  of  lighter  color,  be- 


DISEASES    OF    THE    STOMACH.  457 

cause  it  is  the  contents  rather  of  the  small  than  of  the  large  intes- 
tine.    Sometimes  it  is  perfectly  fluid. 

It  is  commonly  supposed  that  fsecal  vomiting  is  caused  by  an 
inversion  of  the  natural  peristaltic  action  of  the  bowel.  This  doc- 
triue  was  called  in  question  by  "William  Brinton.  He  attributes 
the  reflux  of  fsecal  matter  to  the  peristalsis  itself,  which,  acting  on 
an  obstructed  and  distended  bowel,  occasions  on  the  periphery,  as 
far  as  possible,  the  forward  propulsion  of  the  contents  of  the  in- 
testinal tube,  but  which  also  gives  rise  to  a  current  in  the  opposite 
direction  in  the  fluid  substances  occupying  the  centre  of  the  tube.* 

Pus  in  small  amount  is  sometimes  found  mixed  with  the  vomit 
in  cases  of  large  ulcers  in  the  stomach,  simple  or  cancerous. 
When  in  quantities,  it  is  owing  to  an  abscess  in  the  neighborhood 
of  the  viscus  having  poured  its  contents  into  it.  Still,  pus  is 
rarely  met  with  in  the  matters  expelled.  And  the  same  can  be 
said  of  other  substances  which  may  find  their  way  into  the 
stomach,  like  echinococcus  sacs  and  worms,  and  also  of  masses 
of  false  membrane. 

Blood,  on  the  other  hand,  is  not  infrequently  vomited.  Having 
described  the  appearance  of  the  blood  when  it  comes  from  the 
stomach,  in  treating  of  the  diagnosis  of  hemorrhage  from  the  lungs, 
I  shall,  before  examining  into  the  circumstances  which  cause  a 
hsematemesis,  merely  here  recall  the  fact  that  it  is  preceded  by 
nausea  and  followed  by  black  stools,  and  that  the  fluid  ejected  is 
generally  black,  and  presents  an  acid  reaction. 

The  quantity  of  blood  lost  varies,  of  course,  greatly;  but  the 
amount  vomited  is  by  no  means  a  proof  of  the  amount  effused. 
The  larger  portion  may  pass  off  by  the  bowels,  giving  rise  to 
peculiar  tarry  stools.  Nay,  the  whole  may  be  voided  with  the 
stools  ;  so  that  hemorrhage  from  the  stomach  and  vomiting  of 
blood  are  not  always  synonymous. 

Hemorrhage  occurring  from  the  stomach  is  differently  caused. 
It  may  spring  from  injury  to  the  organ,  or  from  disease  of  its 
coat ;  it  may  be  vicarious  ;  it  may  be  the  consequence  of  disorder 
elsewhere  than  in  the  stomach,  as  of  a  mechanical  obstruction  in 
the  portal  system  ;  it  may  depend  upon  an  altered  state  of  the 
blood.     But  in  all  cases,  however  caused,  with  the  exception  of 

*  Intestinal  Obstruction,  London,  1867. 


458  MEDICAL    DIAGNOSIS. 

those  arising  from  a  large  vessel  being  eaten  into  by  the  process 
of  ulceration,  a  hemorrhage  from  the  stomach  is  an  illustration 
of  that  kind  of  capillary  hemorrhage  which  modern  research  has 
proved  to  lie  almost  invariably  at  the  root  of  the  so-called  hemor- 
rhages "by  exhalation."  The  overdistended  capillaries  burst;  yet 
no  traces  of  their  rupture  can  be  discovered  with  the  unassisted 
eye  after  death.  Xor  is  this  difficult  to  account  for,  when  the 
extreme  minuteness  of  the  vessels  implicated  is  considered. 

In  the  hemorrhage  that  follows  blows  or  kicks  on  the  stomach, 
an  active  hyperemia  of  the  mucous  surface  is  occasioned,  which 
leads  to  the  extravasation  of  blood.  An  active  arterial  hyperaemia 
also  precedes  the  hemorrhage  that  sometimes  follows  the  swal- 
lowing of  irritant  poisons ;  and  it  is  probably  the  cause  of  the 
haematemesis  in  several  of  the  organic  affections  of  the  stomach. 
Of  these,  only  cancer  and  ulcer  are  apt  to  present  hemorrhage  as 
a  prominent  symptom  ;  and  of  these,  again,  it  is  much  more  fre- 
quent in  the  latter  than  in  the  former.  The  blood  eifused  may 
be  so  slight  in  amount  as  to  escape  detection;  and  this  is  especially 
likely  to  happen  when  it  is  intimately  admixed  with  food  or  with 
bile.  Yet,  by  means  of  the  microscope,  the  existence  of  blood- 
corpuscles  in  the  ejected  matter  can  be  always  demonstrated.  The 
fulness  of  the  vessels  may  be  associated  with  degeneration  of  their 
coats,  as,  for  instance,  in  amyloid  degeneration  of  the  stomach. 

When  blood  has  been  detained  for  some  time  in  the  stomach, 
and  has  become  intimately  mingled  with  the  acid  contents  of  the 
organ,  it  loses  entirely  its  natural  appearance.  What  is  termed 
"coffee-ground  vomit"  is  blood  thoroughly  intermixed  with  other 
substances.  It  is  the  result  of  a  comparatively  small  or  gradual 
hemorrhage;  and,  as  this  is  the  kind  which  is  apt  to  happen  in 
gastric  cancer,  it  is  common  in  this  affection.  It  has  been  held  to 
be  pathognomonic  of  it;  but  it  is  not.  It  occurs  in  other  morbid 
states  of  the  organ,  and  is  met  with  in  yellow  fever. 

Vicarious  hemorrhage  from  the  stomach  is  not  infrequent,  and 
especially  frequent  is  that  which  takes  the  place  of  the  menses. 
It  is  not  dangerous.  The  blood  escapes  more  or  less  exactly  at 
the  time  of  the  normal  discharge,  and  while  the  bleeding  lasts 
the  stomach  is  slightly  tender,  and  the  digestion  impaired.  But 
during  the  intervals  there  are  no  signs  of  disturbance  of  the 
functions  of  the  organ,  and  no  pain ;  both  of  which  are  points 


DISEASES    OF    THE    STOMACH.  459 

of  importance  in  distinguishing  between  loss  of  blood  caused  by 
suppressed  menstruation  and  loss  of  blood  caused  by  disease  of 
the  stomach. 

Gastric  hemorrhage,  dependent  upon  a  state  of  passive  congestion 
brought  on  by  an  obstruction  to  the  flow  of  venous  blood,  is  occa- 
sionally seen  in  organic  affections  of  the  heart.  But  it  is  much 
more  common  as  the  result  of  embarrassment  of  the  portal  cir- 
culation, from  tumors,  or  from  affections  of  the  liver  and  spleen. 
It  frequently  attends,  therefore,  cirrhosis  and  enlargement  of  the 
spleen,  and  is  often  joined  to  intestinal  hemorrhage. 

In  gastric  hemorrhage  resulting  from  changes  in  the  blood  the 
vessels  themselves  are  toneless,  and  rupture  easily  or  offer  no  resist- 
ance to  their  altered  contents  escaping.  This  kind  of  hemorrhage 
is  met  with  in  scurvy,  in  typhus  fever,  and  in  yellow  fever. 

We  see  thus  that  blood  is  vomited  from  various  causes,  and 
that  merely  from  the  occurrence  of  heemateniesis  we  can  determine 
nothing  definite  as  to  its  origin.  Yet  the  symptom,  for  a  symptom 
it  always  is,  is  of  serious  import,  and  when  taken  in  connection 
with  others  is  of  great  service  in  diagnosis.  We  ought,  in  chronic 
cases,  first  to  suspect  the  hemorrhage  to  be  due  to  some  organic 
disease  of  the  stomach ;  when  there  is  no  other  proof  of  a  structural 
affection  of  this  organ,  we  turn  to  the  liver,  spleen,  or  heart  for 
its  explanation,  or  examine  carefully  every  part  of  the  abdominal 
cavity,  to  see  whether  or  not  a  tumor  is  the  source  of  the  trouble. 
If  occasioned  by  none  of  these  conditions,  its  cause  lies  probably 
in  altered  blood,  or  in  suppressed  discharges.  Of  course  the  his- 
tory of  the  case  is  indispensable  to  any  induction.  Thus,  in  low 
fevers  there  is  not  often  difficulty  in  determining  what  has  brought 
about  the  hemorrhage.     The  facts  speak  for  themselves. 

There  is,  however,  one  difficulty  present  in  all  instances ;  and 
that  is,  to  tell  whether  the  ejected  blood  has  found  its  way  into 
the  stomach  and  has  been  subsequently  expelled,  or  whether  the 
hemorrhage  is  really  gastric.  The  only  method  to  avoid  being 
deceived  is  to  scrutinize  closely  the  history  and  the  attending  phe- 
nomena. Blood  may  be  introduced  into  the  stomach  by  the  burst- 
ing of  an  aneurism,  or  from  an  ulcerating  pancreas;  or  it  may  have 
been  swallowed  during  an  attack  of  epistaxis  or  of  haemoptysis, 
or  wilfully,  to  excite  sympathy  or  to  escape  punishment. 

So  much  for  vomiting  of  blood,  and  for  the  different  characters 


460  MEDICAL    DIAGNOSIS. 

presented  by  the  vomit.  In  describing  them  we  have  been  led 
away  from  the  indications  they  furnish  in  diseases  of  the  stomach. 
But  it  was  more  convenient  here  to  consider  vomiting  connectedly 
and  somewhat  in  detail,  than  to  be  obliged  to  treat  of  it  in  various 
chapters.  To  return  now  to  the  more  special  symptoms  of  a  de- 
ranged stomach. 

Pain. — Pain  occurs  in  many  of  the  gastric  disorders,  and  is  met 
with  in  every  conceivable  form.  It  is  sometimes  slight,  at  other 
times  violent.  It  is  often  more  a  feeling  of  soreness  than  actual 
pain.  It  may  or  may  not  be  increased  by  pressure,  and  may  either 
be  augmented  or  relieved  by  the  taking  of  food.  If  persistent  or 
severe,  and  accompanied  by  tenderness  at  the  epigastrium,  it  is 
almost  always  linked  to  a  morbid  state  of  the  tissues  of  the  viscus. 
Mere  uneasy  sensations,  on  the  other  hand,  also  happen  in  func- 
tional derangement  of  the  organ  while  the  food  is  being  digested, 
and  may  even  be  attended  with  slight  tenderness  at  the  epigas- 
trium. 

Now,  as  both  pain  and  soreness  to  the  touch  may  be  present  as 
well  in  functional  disturbance  as  in  organic  change,  how  can  we 
tell  with  which  they  are  associated?  Budd*  lays  down  a  law  on 
this  point  which,  on  the  whole,  is  borne  out  by  the  experience  of 
the  profession.  The  pain  and  soreness,  he  affirms,  dependent  on 
organic  disease  may  be  distinguished  from  the  pain  and  soreness 
which  result  from  functional  disorder  by  noticing  the  time  at 
which  they  take  place.  If  they  are  more  severe  soon  after  meals, 
or  when  the  stomach  is  full,  and  more  severe  after  a  heavy  meal 
of  animal  food  than  after  a  light  one  of  farinaceous  substances 
and  milk,  they  point  to  a  structural  affection.  If  they  occur  only 
when  the  stomach  is  empty,  and  are  relieved  by  food,  they  are 
indicative  of  a  functional  derangement.  This  general  rule  is  as 
true  as  most  general  rules;  but  no  truer.  The  confidence  to  be 
placed  in  it  depends  to  some  extent  on  the  meaning  attached  to 
the  word  pain ;  for  the  rule  would  prove  a  very  fallacious  guide 
were  the  uneasiness  and  sense  of  weight  attendant  on  the  act  of 
digestion,  in  those  whose  gastric  juice  is  deficient  in  quantity  or 
in  an  unhealthy  condition,  to  be  regarded  in  the  same  light  as 
pain,  and  as  undeniable  evidence  of  organic  disease. 

*  Diseases  of  the  Stomach. 


DISEASES    OF    THE    STOMACH.  461 

Occasionally  the  stomach  is  the  seat  of  violent  paroxysms  of 
pain.  These  are  at  times  linked  to  a  chronic  organic  affection ;  at 
others  they  are  apparently  connected  with  a  perfectly  sound  state 
of  the  viscus,  and  coexist  with  a  tendency  to  neuralgic  pains  all 
over  the  body ;  at  others,  again,  they  are  brought  about  by  some 
article  of  food  which  the  stomach  does  not  tolerate  or  is  unable 
to  digest.  The  disorder  is  variously  described  under  the  name  of 
gastrodynia  or  gastralgia,  or  as  a  form  of  cardialgia.  The  pain 
is  supposed  to  be  associated  with  or  due  to  a  cramp  of  the  stomach; 
but  whether  it  is  so  or  not,  is  far  from  certain.  When  the  predis- 
position to  it  exists,  exposure  to  cold  and  damp,  a  draught  of  cold 
water  drunk  when  heated,  sudden  and  violent  emotions,  or  a  col- 
lection of  wind  in  the  alimentary  canal,  will  bring  it  on.  And 
this  predisposition  is  met  with  in  gouty  and  rheumatic  persons, 
and  in  those  who  are  debilitated, — in  women  who  are  anaemic,  and 
in  men  who  have  been  exposed  to  exhausting  influences.  Then 
we  also  find  the  gastralgia  interchanged  with  other  neuralgic  or 
spasmodic  affections,  giving  way  to  asthma  or  to  angina  pectoris, 
or,  on  the  other  hand,  occurring  in  their  place. 

The  pain  varies  much  in  intensity:  it  is  usually  severe  and 
agonizing;  but  it  is  not  permanent;  intervals  of  rest  and  comfort 
succeed  to  the  paroxysms  of  harrowing  distress.  During  a  violent 
attack,  the  skin  is  cold,  the  pulse  slow,  there  are  frequently  nausea, 
vomiting,  sometimes  fainting,  and  often  sensations  of  utter  prostra- 
tion and  impending  dissolution.  The  seat  of  the  pain  is  in  the 
epigastrium,  immediately  beneath  the  ensiform  cartilage.  The 
patient  feels  as  if  the  coats  of  the  stomach  were  being  violently 
drawn  together,  or  rent  asunder,  or  rapidly  pierced  by  a  sharp 
instrument.  Thence  the  pain  extends  toward  the  umbilicus  and  the 
hypochondria.  It  is  sometimes  relieved  by  the  recumbent  position 
and  by  external  pressure. 

But  relief,  under  these  circumstances,  depends  much  on  the 
condition  with  which  the  pain  is  associated.  If  it  be  connected 
with  a  chronic  gastritis  or  an  ulceration,  external  pressure  aggra- 
vates rather  than  alleviates  it.  This  is  certainly  true  as  a  general 
rule;  yet  we  cannot  always  positively  announce  that  the  pain  which 
is  conjoined  with  tenderness  at  the  epigastrium  is  a  proof  of  an 
organic  lesion.  There  is  sometimes  sensitiveness  to  the  touch 
in  purely  nervous  gastralgia;   or  slight  pressure  may  augment 


462  MEDICAL    DIAGNOSIS. 

the  pain,  but  firmly  compressing  the  pit  of  the  stomach  will 
diminish  it. 

In  a  practical  point  of  view,  it  is  very  important  to  discriminate 
between  the  cases  of  gastralgia  which  may  be  viewed  as  pure  neu- 
ralgia of  the  stomach  and  those  in  which  the  paroxysms  of  pain 
are  combined  with  a  chronic  lesion.  AVe  infer  that  we  have  to 
deal  with  instances  of  the  former,  when  the  attacks  occur  in  those 
whose  impoverished  blood  or  enfeebled  health  predisposes  to  neu- 
ralgia, and  especially  if  they  happen  in  women  laboring  under 
disorders  of  the  uterus  or  ovaries,  or  in  persons  who  suffer  from 
neuralgic  pains  in  other  parts  of  the  body.  But  the  broadest  line 
of  distinction  is  drawn  from  the  state  of  the  digestive  apparatus 
during  the  intervals.  The  disordered  digestion,  the  pain  after 
eating,  the  tenderness  at  the  epigastrium,  the  nausea  and  vomit- 
ing, and  the  other  symptoms  common  in  morbid  alterations  of 
the  coats  of  the  stomach,  are  not  seen  in  pure  neuralgic  gastro- 
dynia.  I  have  already  stated  that  too  much  stress  ought  not 
to  be  laid  on  the  influence  of  pressure  on  the  paroxysmal  pain 
during  the  paroxysm.  A  sign  more  trustworthy  is  the  alleviation 
following  the  taking  of  food,  for  which,  in  truth,  there  may  be 
a  craving;  and  occasionally  cases  of  gastralgia  are  met  with  in 
which  the  pain  occurs  only  early  in  the  mornings,  and  is  very 
distressing,  but  is  almost  immediately  eased  by  a  hearty  breakfast. 

The  form  of  gastrodynia  which  is  produced  by  some  article  of 
food  that  disagrees  with  the  individual  is  readily  distinguished 
from  the  other  varieties  by  observing  it  to  be  transient,  and  by 
noting  its  cause.  The  indigestible  substance  undergoes  fermenta- 
tion in  the  stomach,  and  acidity,  flatulent  distention,  and  nausea 
attend  the  pain,  which  ceases  when  the  offending  matter  is  ejected 
and  the  gas  expelled. 

The  remarks  just  made  apply  also,  in  the  main,  to  other 
manifestations  of  perverted  innervation  of  the  stomach,  such  as 
hyperesthesia,  erethism,  with  or  without  persistent  vomitings, — 
forms  happening  usually  in  weak  or  hysterical  persons,  but  which 
in  the  present  state  of  our  knowledge  are  still  conveniently  classed 
with  gastralgia. 

The  nervous  filaments,  the  irritation  of  which  occasions  pain 
in  the  stomach  whether  paroxysmal  or  not,  belong  to  the  vagus ; 
sometimes,  perhaps,  the  distress  originates  in  the  branches  of  the 


DISEASES    OF    THE    STOMACH.  463 

sympathetic  that  supply  the  organ.  But  we  must  be  careful  not 
to  ascribe  the  seat  of  every  pain  which  is  felt  between  the  umbili- 
cus and  sternum,  or  referred  there,  to  the  stomach.  Diseases  of 
the  pleura,  of  the  heart  and  its  covering,  affections  of  the  inter- 
costal nerves,  abscess  of  the  liver,  intestinal  disorders,  rheumatism 
of  the  abdominal  muscles,  may  give  rise  to  pain  in  the  epigastric 
region.  And,  again,  spasmodic  pain  like  that  of  gastralgia  may 
be  caused  by  colic,  by  disorganization  of  the  tissue  of  the  kidney 
and  of  the  pancreas,  and  by  the  passage  of  gall-stones  or  of  renal 
calculi.  The  great  safeguard  against  error  is  to  bear  in  mind 
that  painful  complaints  of  the  stomach  may  be  mistaken  for  those 
enumerated,  and  to  ascertain  carefully,  in  cases  of  epigastric  dis- 
tress, that  there  is  no  cause  beyond  the  stomach  to  account  for  it. 
The  nearer,  in  many  instances,  the  pain  is  to  the  median  line,  or, 
should  it  occupy  this,  the  more  fixed  and  confined  to  a  small  spot, 
the  greater  is  the  probability  of  its  being  dependent  upon  gastric 
disease;  and  pain  of  the  character  alluded  to  is  generally  in- 
dicative of  serious  malady. 

Pain  is  the  last  of  the  symptoms  directly  referable  to  the  de- 
rangement of  the  viscus  itself  to  which  we  shall  allude.  But 
when  the  great  organ  of  assimilation  is  disordered,  other  organs 
suffer,  either  through  sympathy,  or  because  the  irritation  is  trans- 
mitted to  them,  or  because  a  similar  state  of  their  mucous  surface 
is  induced.  The  bowels  are  usually  in  a  sluggish  condition  ;  it  is 
commonly  only  when  the  gastric  acidity  is  extreme  that  they  are 
relaxed.  The  viscera  within  the  chest  are  frequently  disturbed. 
The  patient  is  annoyed  by  palpitation  and  shortness  of  breath 
after  meals;  and  as  he  feels  the  agitation  of  his  heart,  and  finds 
that  always,  after  he  has  eaten,  his  face  is  flushed,  the  palms  of 
his  hands  are  hot,  and  his  temporal  arteries  throbbing,  he  is  apt  to 
overlook  the  derangement  of  the  stomach,  and  to  fancy  himself 
laboring  under  an  incurable  cardiac  affection.  A  dry  cough,  also, 
is  a  not  unusual  concomitant ;  but  a  cough  may  be  the  result  of 
coexisting  catarrh  of  the  bronchial  mucous  membrane,  or  of  dis- 
ease of  the  lung-structure;  and  sometimes  the  affection  of  the 
lungs  precedes  that  of  the  stomach. 

So,  too,  with  the  kidneys.  They  may  be  irritated  by  the  crude 
material  which  has  made  its  way  into  the  blood,  and  which  they 
are  called  upon  to  excrete.     The  urine  often  contains  various  ab- 


464  MEDICAL    DIAGNOSIS. 

normal  constituent- ;  yet  not  seldom  a  morbid  state  of  the  urine 
is  found  previous  to  the  derangement  of  the  stomach,  and  the 
indigestion  is  the  secondary  rather  than  the  primary  ailment. 
Indeed,  we  must  never  be  too  hasty  in  concluding,  when  a  dis- 
ordered stomach  is  associated  with  diseases  of  other  viscera,  that 
it  is  their  cause ;  it  may  exist  as  their  consequence.  Diseases  of 
the  liver  and  intestines  are  especially  prone  to  induce  a  gastric 
affection. 

One  of  the  worst  results  of  a  disordered  digestion  is  the  state 
of  mind  it  produces.  It  occasions  listlessness  and  a  disposition 
to  look  at  all  events  in  a  gloomy  light,  and  sometimes  brings  on 
inveterate  hypochondriasis.  Aretseus  ascribed  to  the  stomach  as 
its  primary  power  that  it  acted  as  the  president  of  pleasure  and 
of  disgust,  "being,  from  the  sympathy  of  the  soul,  an  important 
neighbor  to  the  heart  for  imparting  good  or  bad  spirits."  Now, 
although  no  one  at  present  would  agree  with  the  physiology  of 
the  learned  Cappadocian,  who  will  deny  that  there  is  in  the 
remark  a  germ  of  truth  ?  How  few  men  have  not  experienced 
the  depression,  the  lack  of  energy,  which  a  disturbance  in  the 
main  organ  of  digestion  brings  with  it !  But  here,  again,  we 
must  be  careful  not  to  confound  cause  with  effect ;  for  want  of 
activity  or  a  distressed  state  of  mind  may  seriously  impair  the 
appetite  and  subvert  the  normal  action  of  the  viscus.  The 
exquisite  description  of  Juvenal,  in  his  Thirteenth  Satire,  of  the 
conscience-stricken  perjurer,  is  hardly  drawn  with  too  much  poetic 
license : 

"  Perpetua  anxietas  nee  mensa;  tempore  cessat, 
Faucibus  ut  morbo  siecis,  interque  molares 
Difficili  creseente  cibo  :  sed  vina  misellus 
Exspuit ;  Albani  veteris  pretiosa  senectus 
Displicet :  ostendas  melius,  densissima  ruga 
Cogitur  in  frontem,  velut  acri  ducta  Falerno." 

In  the  rough  sketch  just  finished  of  the  symptoms  encountered 
in  gastric  disorders,  no  attempt  has  been  made  to  separate  the 
signs  which  belong  more  particularly  to  alteration  of  its  coats 
from  those  which  occur  in  derangement  of  its  functions;  in  other 
words,  I  have  not  tried  to  dissociate  the  symptoms  of  "  dyspepsia" 
from  those  of  actual  lesions. 

And  this  for  two  reasons :  in  the  first  place,  the  most  palpable 


DISEASES    OF    THE    STOMACH.  465 

indications  of  organic  disease  of  the  stomach  are  those  of  dis- 
ordered function ;  and  secondly,  there  are  no  symptoms  which 
belong  exclusively  to  dyspepsia.  This  complaint  consists  simply 
of  the  phenomena  of  indigestion,  but  in  infinitely  varied  combi- 
nation :  in  some  cases  we  find  pain ;  in  others,  nausea  and  disgust 
for  food ;  in  others,  again,  uneasiness  after  meals,  and  acid  eruc- 
tations, or  flatulency ;  in  some  the  gastric  symptoms  are  connected 
with  debility,  with  great  depression  of  spirits,  and  with  wasting; 
in  others  a  fair  amount  of  health  is  preserved,  the  appetite  is 
uncertain  or  perverted,  and  the  signs  of  indigestion  are  manifest 
only  after  certain  articles  of  food  have  been  partaken  of;  in  some 
cases  the  nervous  symptoms  are  more  prominent  than  the  gas- 
tric ;  in  others  the  dyspeptic  symptoms  may  be  the  most  marked, 
although  the  real  cause  is  an  exhausted  state  of  the  nervous  system. 

Thus  it  is  impossible  to  present  anything  like  a  complete  pic- 
ture of  merely  functional  dyspepsia.  Nor  is  this  necessary;  for  its 
main  features  are  easily  enough  recognized.  In  truth,  the  liability 
to  error  lies  in  an  opposite  direction.  The  faulty  performance  of 
the  act  of  digestion  is  too  often  regarded  as  the  whole  ailment. 
Too  often,  if  the  practitioner  have  made  out  the  diagnosis  of  "dys- 
pepsia," he  seeks  no  further,  and  treats  the  patient  for  this,  and 
this  alone,  by  means  of  some  of  the  interminable  mixtures  which 
enjoy  the  reputation  of  being  "  good  for  dyspepsia."  He  does  not 
remember,  or  choose  to  remember,  that  dyspepsia  may  be  bound  as 
a  symptom  to  structural  alteration  of  the  stomach ;  just  as  palpi- 
tation and  irregular  action  of  the  heart  may  constitute  the  whole 
complaint,  but  may  also  be  joined  to  serious  valvular  lesion.  It 
is  true  that  in  an  organ  like  the  stomach  it  is  particularly  difficult 
to  tell  where  disturbed  function  ceases  and  anatomical  change 
begins.  Still,  that  this  can  be  done  to  a  greater  extent  than  it  is 
usually  done,  cannot  be  gainsaid. 

Moreover,  there  are  a  great  many  affections  which  probably 
have  connected  with  them  definite  anatomical  lesions  and  con- 
stant modifications  of  the  gastric  juice  and  of  the  secretions  of 
the  mucous  follicles  of  the  stomach,  which  we  are  as  yet  obliged 
to  embrace  under  the  name  of  dyspepsia ;  and  this  because  we 
are  unacquainted  with  their  clinical  expression.  But  we  may 
fairly  hope  that,  through  those  admirable  physiological  and 
pathological  researches  which  have  of  late  begun  to  illuminate 

30 


466  MEDICAL    DIAGNOSIS. 

the  subject,  our  ignorance  will  be  dispelled,  and  by  their  aid 
we  may  expect  the  limits  of  purely  functional  dyspepsia  to  be 
much  reduced ;  so  that  what  the  physician  of  the  present  day 
is  compelled  to  class  under  the  general  term  dyspepsia  will  be 
recognized  by  the  physician  of  the  twentieth  century  as  several 
distinct  affections,  each  with  its  characteristic  structural  change, — 
much  in  the  same  way  that  the  physician  of  the  eighteenth  cen- 
tury was  obliged  to  regard  and  to  treat  dyspnoea  as  an  individual 
disease,  while  now  we  have  learned  to  separate  it  into  different 
varieties,  in  conformity  with  its  prominent  anatomical  causes,  and 
to  treat  it  in  accordance  with  its  source. 


Diseases  of  the  Stomach  in  which  Pain  and  Soreness  at  the 
Epigastrium,  and  Vomiting,  occur, 

After  what  has  been  premised,  it  is  obvious  that  the  structural 
diseases  of  the  stomach,  as  far  as  they  are  known  up  to  this  time, 
present  but  few  symptoms  which  can  be  regarded  as  at  all  charac- 
teristic. Indeed,  the  only  ones  which  can  lay  any  claim  to  be  so 
considered — and  we  have  already  seen  that  this  claim  is  not  always 
valid — are  pain  and  soreness  at  the  epigastrium,  and  vomiting. 
We  may,  then,  take  these  symptoms  as  a  starting-point  in  diag- 
nosis, and  describe  the  individual  organic  affections  in  which  they 
chiefly  occur,  speaking  first  of  those  which  are  acute. 

Acute  Gastritis. — This  malady  is  now  pronounced  by  all 
authors  to  be  exceedingly  rare,  save  as  the  result  of  irritant 
poisons.  Yet  there  was  a  time,  and  that  not  fifty  years  ago, 
when  acute  inflammation  of  the  stomach  was  held  to  be  very  fre- 
quent, and  when  this  idea  was  made  the  keystone  of  a  wTondrous 
edifice  of  pathological  and  therapeutic  theory,  which  counted  its 
admirers  by  hundreds  in  every  part  of  the  civilized  world.  The 
discrepancy  of  opinion  as  regards  the  frequency  of  the  disease 
may,  to  some  extent,  be  explained  by  the  varying  latitude  given 
to  the  term  inflammation.  Undoubtedly,  inflammation  of  an 
intense  kind,  involving  more  than  the  mucous  membrane,  origi- 
nating spontaneously,  and  not  from  the  introduction  of  any  highly 
acrid  or  corrosive  substance  into  the  stomach,  is  very  seldom  met 
with.  But  it  is  no  less  certain  that  inflammation  of  a  less  active 
character,  limited  to  the  most  important  part  of  the  stomach,  to 


DISEASES    OF    THE    STOMACH.  467 

the  mucous  membrane,  and  especially  to  its  surface,  is  far  from 
being  a  rare  disease,  and,  whether  as  a  concomitant  of  fevers  or 
as  an  idiopathic  malady,  is  a  disorder  to  which  the  practitioner's 
attention  is  constantly  drawn. 

Thus,  then,  acute  inflammation  of  all  the  coats  of  the  stomach, 
or  even  of  the  entire  mucous  membrane,  is  uncommon ;  acute  in- 
flammation of  its  surface  is  common.  Yet  it  is  the  doctrine  of 
the  day  not  to  regard  any  case  as  acute  gastritis  unless  serious 
changes  have  been  wrought  by  the  inflammation  in  the  tissues  of 
the  organ,  so  serious  as  almost  to  preclude  recovery.  To  discuss, 
in  a  work  of  this  kind,  the  correctness  or  incorrectness  of  this 
view,  would  hardly  be  justifiable.  But,  before  proceeding,  I 
venture  to  submit  whether  the  limits  within  which  acute  inflam- 
mation is  supposed  to  be  confined  are  not  more  rigidly  marked 
out  for  the  stomach  than  for  any  other  viscus ;  whether  it  is  not 
very  arbitrary  and  artificial  to  make  severity  and  consequence  the 
test  of  acute  inflammation ;  and  whether  a  state  of  things  fully 
entitled  to  be  called  acute  idiopathic  gastritis  is  not  more  frequent 
than  is  generally  admitted.  I  am  sure  that  I  have  seen  cases  which 
differed  in  nothing  from  the  typical  and  graphically  described 
cases  of  Andral,*  save  in  the  fatal  termination  and  in  lacking  the 
symptoms  which  immediately  precede  that  termination. 

I  shall  detail  one  which  was  striking.  A  robust  woman,  the 
mother  of  several  children,  whom  she  was  obliged  to  support  by 
hard  labor,  was  suddenly  seized  with  a  pain  in  the  epigastric 
region,  and  vomiting.  There  was  no  apparent  cause  for  the  at- 
tack :  she  had  certainly  not  swallowed  any  irritating  substance. 
Although  at  one  time  a  sufferer  from  indigestion,  her  digestive 
organs  had  not  been  markedly  disordered  for  weeks  prior  to  the 
appearance  of  the  pain  and  the  irritability  of  the  stomach.  The 
former  seemed  to  come  on  before  the  latter.  It  was  of  a  dull 
character,  increased  by  swallowing  either  solids  or  liquids,  and 
associated  with  the  greatest  tenderness.  Nausea  was  constant,  and 
vomiting  very  frequent.  Large  quantities  of  a  greenish  fluid 
were  ejected,  as  well  as  nearly  everything  she  swallowed.  The 
tongue  was  deeply  coated;  its  edges  and  tip  were  red.  The  bowels 
were  constipated,  but  not  painful  on  pressure.     There  was  fever, 

*  Clinique  Medicale,  tome  ii. 


468  MEDICAL    DIAGNOSIS. 

not,  however,  of  an  active  type;  the  skin  was  hot  toward  evening; 
the  pulse  quick  and  small ;  the  breathing  was  hurried,  and  the 
patient  exceedingly  restless  and  prostrated.  She  complained  most 
of  the  distress  in  her  head,  and  of  violent  thirst.  The  treatment 
pursued  consisted  mainly  in  opening  the  bowels  by  enemata,  and 
in  administering  ice  and  repeated  doses  of  calomel,  some  of  which 
she  retained.  After  the  symptoms  had  lasted  for  about  ten  days, 
they  gradually  disappeared,  and  she  slowly  recovered.  The  pain 
on  swallowing  and  the  soreness  at  the  epigastrium  were  the  last  to 
leave.  Indeed,  when  she  passed  from  under  my  care  they  had 
not  ceased  entirely.  I  cannot  say  whether  they  ever  did,  for  I 
lost  sight  of  the  patient. 

Now,  here  is  a  case  which  presented  all  the  symptoms  of  a 
severe  inflammation  of  the  stomach,  similar  to  that  produced  when 
an  irritant  poison  has  been  received  into  the  organ.  In  all  such 
instances  there  are  the  same  nausea  and  vomiting,  and  pain  ;  the 
same  restlessness  and  headache ;  the  same  form  of  fever  and  small 
or  feeble  pulse;  the  same  unquenchable  thirst.  Sometimes  the 
pain  is  of  a  burning  kind ;  and  in  those  cases  which  prove  fatal 
— and  many  do  prove  fatal,  as  much  perhaps  from  the  destructive 
effect  of  the  irritant  on  the  tissues  as  in  consequence  of  the  inflam- 
mation— there  is  hiccough,  the  skin  becomes  cold,  the  features 
collapse,  and  the  sufferer  dies  prostrated,  yet  frequently  preserving 
his  mental  faculties  to  the  last. 

From  these  severe  cases  of  acute  gastritis,  however  caused,  there 
exists  every  grade  of  inflammation,  down  to  an  active  congestion 
of  the  mucous  membrane,  and  to  a  mere  reddening  of  its  surface. 
Of  course,  there  will  not  be  in  the  milder  forms  the  same  intensity 
in  the  symptoms.  But  the  outline  is  the  same,  although  the  filling 
in  be  in  far  less  vivid  hues.  There  is  in  all  the  same  tendency  to 
nausea  and  to  vomiting,  with  more  or  less  epigastric  pain  and 
uneasy  sensations,  and  more  or  less  tenderness  at  the  pit  of  the 
stomach,  and  headache. 

A  mild  gastritis  is  very  commonly  brought  on  by  a  debauch  or 
by  the  introduction  of  irritating  articles  of  diet  into  the  stomach. 
These  cases  are  classed  by  some  as  acute  gastric  catarrh,  and  pop- 
ularly known  as  severe  attacks  of  indigestion  :  that  they  are  owing 
to  an  inflammatory  state  of  the  mucous  membrane  was  proved  by 
the  ocular  demonstration  Dr.  Beaumont  had  of  the  process  in  the 


DISEASES    OF    THE    STOMACH.  469 

person  of  Alexis  St.  Martin.  Dr.  Beaumont  found  that  when- 
ever Alexis  had  been  eating  plentifully  of  substances  hard  of 
digestion,  or  drinking  freely  of  ardent  spirits,  the  raucous  surface 
of  the  stomach  exhibited  patches  of  redness  of  various  size,  from 
which  now  and  then  small  drops  of  blood  exuded.  Aphthous 
spots  were  also  detected,  and  the  secretions  were  evidently  arrested, 
although  occasionally  a  considerable  quantity  of  ropy  mucus  col- 
lected on  the  surface  of  the  membrane.  The  symptoms  these 
changes,  when  they  were  marked,  produced,  were  some  tenderness 
at  the  epigastrium;  nausea;  vomiting;  constipation,  or  sometimes 
diarrhoea;  a  coated  tongue,  and  headache, — in  fact,  just  the  symp- 
toms of  which  patients  complain  when  they  are  suffering  from  an 
acute  attack  of  indigestion. 

Another  common  and  kindred  kind  of  mild  inflammation  of 
the  stomach  is  that  usually  called  a  "  bilious  attack."  The  French 
designate  it  expressively  as  embarras  gastrique.  English  writers, 
borrowing  a  term  from  the  Germans,  describe  it  as  a  variety  of 
acute  gastric  catarrh.  In  truth,  it  is  like  a  catarrhal  affection,  and 
is  often  associated  with  catarrh  of  other  mucous  membranes.  It 
sometimes  occurs  in  epidemics.  The  symptoms  are  those  already 
detailed.  There  is  nausea,  and  frequently  bile  is  vomited.  We 
do  not  usually  observe  much  pain  in  the  epigastrium;  but  rather 
a  feeling  of  uneasiness,  and  a  slight  soreness  to  the  touch.  The 
urine  is  commonly  dark,  and  deposits  urate  of  ammonium ;  the 
tongue  is  much  coated ;  there  is  thirst,  with  generally  a  slight 
fever,  which  exacerbates  at  night.  From  the  latter  circumstance, 
remittent  fever  is  treated  of  by  some  authors  as  an  acute  gastric 
catarrh;  but  this  is  giving  to  one  of  the  phenomena  in  this  disease 
a  prominence  to  which  it  is  not  entitled. 

Secondary  acute  inflammation  of  the  mucous  membrane  of  the 
stomach  is  found  in  association  with  various  disorders.  It  is  met 
with  in  remittent  fever,  in  typhus,  in  the  exanthemata,  in  rheu- 
matism, and  oftener  in  gout,  and  partakes  somewhat  of  the  specific 
character  of  the  malady  with  which  it  happens  to  be  combined. 
Indeed,  instead  of  being  a  secondary  inflammation,  it  is  oftener, 
to  speak  correctly,  a  local  expression  of  a  constitutional  state. 

Several  writers  describe  a  form  of  gastritis  which  occurs  in  very 
young  children  and  leads  to  softening  of  the  mucous  lining  of 
the  stomach.     Jaeger,  Cruveilhier,  and  Billard  in  particular  have 


470  MEDICAL    DIAGNOSIS. 

made  this  acute  gastric  softening  the  subject  of  special  study.  Yet 
its  nature  is  not  fully  understood.  There  are  some  who  believe 
the  gelatinous  softening  to  be  the  consequence  of  inflammation ; 
others  who  regard  it  as  nothing  but  the  post-mortem  result  of  the 
solvent  powers  of  the  gastric  juice;  while  others,  again,  maintain 
it  to  be  due  to  a  pathological  process  that  is  not  inflammatory,  but 
which  has  disorganized  the  tissues  during  life.  The  symptoms 
which  are  ascribed  to  the  malady  are  certainly  exactly  like  those 
of  acute  inflammation  of  the  stomach.  As  I  have  no  experience 
in  this  strange  disorder,  I  shall  follow  closely  the  delineation  given 
of  it  by  Billard.* 

The  disease  usually  begins  with  the  signs  of  a  violent  gastritis, 
with  tension  of  the  epigastric  region,  which  is  painful  to  the 
touch  ;  with  vomiting,  not  only  of  the  milk  and  of  the  other 
liquids  swallowed,  but  also  of  a  green  or  yellow  fluid.  This 
vomiting  happens  either  immediately  or  some  time  after  the  child 
has  taken  food  or  drink.  There  is  occasionally  diarrhoea;  and  the 
discharges  from  the  bowels  are  frequently  greenish,  resembling 
those  from  the  stomach.  The  respiration  is  hurried  and  jerking ; 
the  extremities  are  cold ;  the  face  and  cry  are  expressive  of  suffer- 
ing; the  agitation  is  great.  To  this  state  succeeds  one  of  general 
prostration  and  insensibility,  and  at  the  end  of  six,  eight,  or  fifteen 
days  the  patient  dies  exhausted,  from  want  of  sleep  and  from  the 
constant  vomiting  and  pain.  In  very  young  children  there  is 
hardly  any  fever.  The  disease  sometimes  runs  a  more  chronic 
course.  It  may  be  combined  with  a  similar  softening  of  the  in- 
testines. Cruveilhier  has  seen  it  occur  in  epidemics.  He  describes 
a  prodromic  period,  marked  by  a  rapid  loss  of  strength,  and  by 
intense  thirst. 

Chronic  Diseases  attended  with  Pain,  Epigastric  Tenderness, 
and  Vomiting. 

The  chronic  diseases  of  the  stomach  may,  like  the  acute,  be 
considered  in  accordance  with  the  pain,  the  soreness  at  the  epigas- 
trium, and  the  vomiting  that  attend  them.  At  all  events,  these 
are  the  symptoms  common  to  the  chronic  diseases  which  are  sus- 

*  Maladies  des  Enfants  nouveau-nes. 


DISEASES    OF    THE    STOMACH.  471 

ceptible  of  diagnosis.  Besides  these,  there  are  some  chronic  dis- 
orders with  the  morbid  anatomy  of  which  recent  careful  researches 
have  made  us  familiar, — such  as  destruction  of  the  tubular  struc- 
tures; hypertrophy  of  the  solitary  glands;  interstitial  growths 
leading  to  glandular  wasting,  and  to  a  gradual  fibroid  thickening 
of  the  entire  mucous  or  submucous  coat;  fatty  degeneration  of 
the  atrophied  masses,* — but  which  we  are  as  yet  unable  to  dis- 
tinguish at  the  bedside,  and  which,  so  far  as  has  been  ascertained, 
may  even  be  entirely  latent. 

Contrasting  the  chronic  diseases  with  which  we  are  clinically 
acquainted  with  the  acute,  vomiting  is  found  to  be  a  symptom  of 
greater  diagnostic  value, — not  the  act  itself,  but  the  appearances 
of  the  ejected  matter.  And,  further,  the  phenomena  of  dyspepsia 
stand  forth  much  more  conspicuously. 

Chronic  Gastritis. — In  chronic  inflammation  of  the  mucous 
membrane,  or  chronic  gastric  catarrh,  the  symptoms  of  indigestion 
are  persistent  and  manifold.  They  vary  somewhat  according  to 
the  extent  of  the  mucous  surface  involved  and  the  amount  of 
mucus  and  epithelium  which  accumulates  on  it,  and  probably  also 
according  to  the  healthy  or  wasted  state  of  the  gastric  glands. 
Generally  there  is  a  sensation  of  discomfort,  of  weight,  and  of 
soreness  at  the  pit  of  the  stomach,  aggravated  by  food ;  the  part 
is  also  tender  to  the  touch.  Sometimes,  even  when  the  stomach 
is  empty,  a  burning  at  the  epigastrium  and  an  inward  fever  are 
complained  of.  The  appetite  is  impaired  or  capricious.  Fer- 
mentation, heart-burn,  and  flatulency  frequently  attend  the  slow 
digestion  of  the  food ;  the  tongue  is  usually  heavily  coated ;  it 
may,  however,  be  clean.  The  bowels  are  constipated.  The  urine 
contains  an  excess  of  phosphates  or  urates,  or  exhibits  crystals  of 
oxalate  of  lime.  The  patient's  circulation  is  languid.  He  suffers 
from  chilliness.  His  spirits  are  depressed.  Xot  unfrequently, 
when  the  case  has  been  of  long  duration,  he  is  annoyed  by  thirst, 
and  by  vomiting,  after  meals,  the  half-digested  food  mixed  with 
strings  of  mucus.  But  the  vomiting  may  also  take  place  when 
the  stomach  is  empty,  and  the  ejected  matter  is  then  fluid  and 
colorless.      Drunkards  who    suffer   from  chronic  gastritis    often 

*  See  Handfield  Jones,  Pathological  and  Clinical  Observations  respecting 
Morbid  Conditions  of  tbe  Stomach ;  and  Wilson  Fox,  Diseases  of  the  Stomach, 
1872. 


472  MEDICAL    DIAGNOSIS. 

throw  up  a  quantity  of  glairy  fluid  on  rising  in  the  morning.  A 
colorless  vomit,  joined  to  symptoms  of  long-continued  indigestion, 
is  always  very  characteristic  of  chronic  gastritis. 

Thus,  then,  occasionally  the  character  of  the  vomit,  more  fre- 
quently the  coated  tongue,  the  distress  after  eating,  the  soreness 
at  the  epigastrium,  and,  especially,  the  permanence  of  the  symp- 
toms, distinguish  the  dyspepsia  of  chronic  inflammation  of  the 
stomach  from  that  which  is  purely  functional ;  for,  although  cases 
of  chronic  gastritis  may  recover,  and  often  do  recover,  yet  the 
amelioration  is  very  gradual,  and  months  or  years  elapse  before 
restoration  to  health  takes  place. 

The  causes  of  the  malady  are  at  times  obscure.  It  certainly 
cannot  always,  nor  in  truth  frequently,  be  traced  to  an  antecedent 
acute  attack,  although  those  who  suffer  from  the  chronic  disorder 
are  particularly  prone  to  acute  exacerbations.  It  is  more  common 
in  persons  over  than  under  forty  years  of  age.  It  is  especially 
common  in  gourmands  and  drunkards,  and  in  those  who  live  on 
coarse  food.  It  is  often  found  conjoined  with  chronic  bronchitis, 
and  sometimes  with  tubercular  disease  of  the  lungs,  or  with  amy- 
loid degeneration.  Passive  congestion  undoubtedly  acts  as  a  pre- 
disposing element.  The  inflammation  is  seen  to  arise  from  this 
cause  in  the  course  of  chronic  affections  of  the  heart,  of  the  liver, 
and  of  obstructions  to  the  portal  circulation,  whether  complicated 
with  a  lesion  of  the  liver  or  not. 

Chronic  gastritis  is  frequently  associated  with  ulcers  in  the 
organ  or  with  cancer,  and  many  of  the  symptoms  of  these  dis- 
orders are  clearly  attributable  to  it.  Let  us  inquire  whether 
there  are  any  special  symptoms  to  inform  us  that  something  more 
dangerous  than  chronic  inflammation  of  the  mucous  membrane 
of  the  stomach  exists. 

Gastric  Ulcer. — Ulcer  of  the  stomach  is  a  disease  compara- 
tively rare  in  this  country ;  but  it  is  not  so  in  some  parts  of  the 
Continent  of  Europe  and  in  England.  Nor  is  it  even  in  this 
country  so  rare  that  I  have  not  seen  a  number  of  undoubted  cases 
of  the  affection. 

The  ulcer  or  ulcers,  for  there  are  sometimes  several  present, 
are  seated  most  usually  on  the  posterior  wall  of  the  stomach,  in 
or  near  the  lesser  curvature  and  toward  the  pyloric  extremity. 
The  great  danger  arises  from  perforation  of  the  coats  and  subse- 


DISEASES    OF    THE    STOMACH.  473 

qnent  peritonitis.  But  the  ulceration  may  prove  fatal  by  opening 
a  large  blood-vessel.  Again,  the  formation  of  a  gastro-colic  or 
a  gastro-pulmonary  fistula  may  lead  to  death ;  or  the  protracted 
suffering  and  excessive  vomiting  may  gradually  exhaust  the  vital 
energies.  On  the  other  hand,  the  ulcers  may  heal  by  cicatrization  ; 
and  this,  William  Brinton  tells  us,  takes  place  in  about  half  the 
instances.     Recurrence  of  the  affection  is  not  uncommon. 

In  cases  which  may  be  regarded  as  typical,  the  malady  is  an- 
nounced by  symptoms  exactly  like  those  witnessed  in  chronic 
gastritis, — the  same  uneasiness  and  pain  at  the  epigastrium,  and 
occasional  nausea  and  vomiting  of  food,  or  of  a  watery  fluid. 
Perforation  may  at  this  early  stage  of  the  disease  most  unexpect- 
edly cut  short  the  patient's  life.  Should  perforation  not  take 
place,  hemorrhage  from  the  stomach,  with  emaciation  and  anaemia, 
next  appears.  In  this  way  the  disease  usually  continues  for  several 
months,  or  sometimes  for  a  much  longer  period,  the  symptoms  re- 
mitting from  time  to  time,  and  showing  singular  variations  in  their 
severity. 

Of  these  symptoms,  pain  and  vomiting  are  the  most  character- 
istic. Pain  is  rarely  absent  j  never,  perhaps,  except  in  cases  which 
run  a  rapid  course.  It  is  generally  a  continuous  dull  feeling ; 
sometimes  a  burning,  at  other  times  a  gnawing  sensation.  As  a 
rule,  it  is  rendered  more  acute  within  a  quarter  of  an  hour  after 
eating,  and  remains  so  as  long  as  food  occupies  the  stomach.  Its 
situation  is  commonly  in  the  middle  of  the  epigastric  region,  and 
there-  it  continues  strictly  limited.  At  that  point,  too,  there  is 
localized  soreness,  or  even  great  tenderness  to  the  touch.  Some- 
times the  pain  is  seated  behind  the  ensiform  cartilage,  or  is 
referred  to  the  right  or  to  the  left  hypochondrium.  It  is  often 
associated  with  a  gnawing  pain  in  the  lower  dorsal  vertebras, 
which  may  shoot  between  the  scapulae  or  down  the  spine;  but 
the  dorsal  pain,  like  the  epigastric,  is,  on  the  whole,  very  fixed, 
radiates  but  little,  and  is  most  severe  when  the  ulcer  is  on  the 
posterior  surface.  Besides  this  continued  feeling  of  distress, 
there  occur  violent  paroxysms  of  pain,  which  may  last  for  sev- 
eral hours;  nay,  with  trifling  intermissions,  for  days.  They  are 
aggravated  by  pressure  or  by  food ;  and,  in  fact,  they  are  often 
thus  induced,  but  not  always,  for  they  sometimes  come  on  sud- 
denly when  the  viscus  is  empty.     The  patient  refers  the  suffering 


474  MEDICAL    DIAGNOSIS. 

chiefly  to  the  pit  of  the  stomach,  or  to  the  dorsal  vertebrae.  He 
is  apt  to  seek  the  recumbent  posture  for  its  relief.  Yet  it  is 
not  a  little  remarkable  that  there  are  sometimes  long  intervals 
during  which  all  pain,  whether  paroxysmal  or  not,  ceases,  and 
during  which  food  can  be  taken  without  inconvenience. 

The  peculiarities  the  pain  exhibits  form,  on  the  whole,  the 
most  distinctive  symptom  of  gastric  ulceration.  The  paroxysms 
just  spoken  of  might  be  mistaken  for  a  purely  nervous  gastralgia. 
And,  indeed,  when  it  is  considered  that  both  disorders  are  speci- 
ally apt  to  occur  in  anaemic  women,  and  in  those  whose  menstrual 
functions  are  deranged,  it  becomes  apparent  how  easily  this  mis- 
take may  be  committed.  The  soreness  at  the  epigastrium ;  the 
persistent  symptoms  of  indigestion ;  the  increase  of  pain  after 
meals — constitute,  in  a  diagnostic  point  of  view,  the  safeguard 
against  error.  To  these  might  be  added  the  vomiting  of  blood, 
were  it  not  that  vicarious  hemorrhages  are  not  at  all  unlikely 
to  take  place  in  young  women  who  are  troubled  with  amenor- 
rhcea.  This  is,  in  truth,  a  matter  having  a  close  connection  with 
the  diagnosis  of  gastric  ulceration.  Persons  who  suffer  from  dis- 
turbance of  the  menstrual  function  are  prone  to  be  hysterical ; 
and  it  may  happen  that  one  of  the  most  marked  traits  of  the 
hysterical  disorder  is,  that  it  manifests  itself  by  tenderness  in 
the  epigastric  region,  and  by  pain  in  the  stomach. 

"We  thus  may  have  the  most  significant  signs  of  gastric  ulcer, 
occurring,  as  so  many  cases  of  amenorrhoea  do,  in  chlorotic  young 
women  ;  therefore  happening  in  the  class  among  whom  ulceration 
of  the  stomach  is  most  frequent.  Nay,  the  very  history  may  point 
to  the  probability  of  gastric  ulcer.*  Yet  generally,  by  close  atten- 
tion to  all  of  the  phenomena  of  the  case,  we  can  arrive  at  a  correct 
conclusion.  The  tenderness  in  the  simulated  malady,  as  in  all  local 
hysterical  affections,  is  great  on  the  slightest  toucli ;  and  there  is 
no  severe  pain  posteriorly  corresponding  to  the  spot  of  soreness  in 
the  epigastric  region.  Pressure  upon  a  spinous  process  may  cause 
pain;  but  it  is  not  the  peculiar  dorsal  pain  of  gastric  ulceration. 
Then,  in  the  hysterical  complaint  there  is  often  hyperaesthesia  of 
the  skin  in  various  portions  of  the  body,  and  the  apparent  gastric 

*  Case  under  my  care,  Philadelphia  Hospital ;  Medical  and  Surgical  Ke- 
porter,  Feh.  1863. 


DISEASES    OF    THE    STOMACH.  475 

distress  bears  no  relation  to  the  taking  of  food  or  to  the  circum- 
stance of  its  being  of  an  irritating  character  or  otherwise. 

But  to  return  to  the  vomiting  of  blood.  When  this  is  not 
traceable  to  a  suppression  of  a  natural  discharge,  and  when  it 
does  not  befall  a  person  who  suffers  from  disease  of  the  heart,  or 
liver,  or  spleen,  or  oesophagus,  it  acquires  great  significance.  It 
is  the  only  kind  of  vomit  at  all  distinctive  of  a  gastric  ulcer ;  for 
the  substances  ejected  present  otherwise  appearances  not  different 
from  what  they  do  in  chronic  gastritis.  The  blood  may  be  pure 
and  red,  but  it  is  more  frequently  blackened  by  the  gastric  juice ; 
and  large  quantities  are  sometimes  passed  by  stool.  Now,  hem- 
orrhage does  not  take  place  in  chronic  inflammation  of  the  mucous 
membrane  of  the  stomach,  except  perhaps  in  drunkards.  In  those 
instances  in  which  erosions  exist  on  the  surface,  the  vomited 
mucus  may  be  a  little  streaked  with  blood ;  yet  anything  like  a 
profuse  hemorrhage  never  happens.  Hence  its  occurrence  in  a 
case  with  the  symptoms  of  chronic  gastritis  renders  the  presence 
of  an  ulcer  probable. 

The  vomiting  of  the  matters  taken  into  the  stomach  may  be 
immediate  or  not  for  some  time  after  the  food  has  been  swallowed. 
Usually  it  happens  speedily,  and  in  some  instances  so  speedily 
that  there  seems  to  be  rather  regurgitation  than  vomiting.  But 
this  is  rare,  and  in  the  rarity  is  a  safeguard  against  confounding 
gastric  ulcer  with  the  vomiting  of  cerebral  disease,  especially 
tumor ;  which  I  have  known  to  happen  in  a  young  woman,  in 
whom,  moreover,  vomiting  of  blood  had  occurred.  In  the  re- 
gurgitation, then,  in  the  frequently  absent  nausea,  in  the  clean 
tongue, — though  coating  may  also  be  absent  in  ulcer, — in  the  want 
of  oppression  and  weight  at  the  epigastrium,  and  in  the  head- 
ache, altered  vision,  and  other  nervous  phenomena,  we  have 
the  distinguishing  traits  between  gastric  and  cerebral  vomiting 
on  which  to  lay  stress  in  the  diagnosis  between  disease  of  the 
brain  and  gastric  ulcer,  or  indeed  any  other  serious  stomach 
affection.  When  error  happens,  it  is  apt  to  be  from  over- 
looking the  brain  disorder  on  account  of  the  prominence  of  the 
gastric  symptoms. 

In  concluding  this  sketch  of  gastric  ulceration,  two  questions 
arise  which  require  solution :  Does  an  ulcer  always  produce  the 
peculiar  train  of  symptoms  mentioned  ?     May  not  the  same  phe- 


476  MEDICAL    DIAGNOSIS. 

nomena  be  met  with  in  other  disorders?  The  first  question  must 
be  answered  in  the  negative.  Many  a  case  of  ulceration  of  the 
stomach  occasions  nothing  but  the  symptoms  of  chronic  gastritis ; 
and  even  .these  may  not  be  marked.  The  second  question  is  to 
be  answered  in  the  affirmative.  There  is  a  disorder  with  symp- 
toms almost  identical  with  gastric  ulceration,  namely,  the  corrosive 
ulcer  of  the  duodenum.  Now,  this  affection,  were  it  more  frequent, 
would  be  a  constant  source  of  error.  ■  It  may  run  an  acute,  or  at 
least  an  apparently  acute,  or  a  chronic  course.  In  either  case  it 
is  scarcely  distinguishable  from  gastric  ulceration.  Trier,*  from 
an  analysis  of  twenty -six  cases,  mentions,  as  the  most  important 
grounds  for  a  differential  diagnosis,  signs  of  dilatation  of  the 
stomach ;  a  sensitive  tumor  in  the  epigastrium,  proceeding  from 
adhesion  with  the  pancreas;  and  jaundice  or  other  hepatic  phe- 
nomena. But  these  symptoms  are  far  from  constant ;  and,  in  accord- 
ance with  his  own  showing,  in  the  acute  cases,  and  in  those  chronic 
cases  which  run  a  latent  course,  the  diagnosis  is  impossible.  It 
may  be  added  that  the  perforating  ulcer  of  the  duodenum  is  much 
more  apt  than  ulcer  of  the  stomach  to  remain  latent,  and  to  lead 
suddenly  to  a  fatal  termination.  It  is  thought  by  some  authorities 
to  be  almost  invariably  due  to  the  action  of  a  highly  acid  gastric 
juice,  and  to  furnish  the  best  illustration  of  the  so-called  "peptic 
ulcer."  It  is  most  common  between  thirty  and  forty  years  of 
age,  and,  as  Krauss  proves,  is  ten  times  more  common  in  men  than 
in  women. 

There  is  yet  another  affection  with  symptoms  like  those  of  ulcer, 
an  affection  still  more  serious  and  destructive, — cancer. 

Gastric  Cancer. — Cancer  is  found  more  frequently  in  the 
stomach  than  in  any  other  organ  except  the  uterus.  Of  nine 
thousand  one  hundred  and  eighteen  cases  of  cancer  which  occurred 
in  Paris  from  1837  to  1840,  two  thousand  three  hundred  and  three 
were  in  the  stomach. f  The  disease  is  generally  primary.  It  is 
most  often  seated  at  the  pylorus;  next  in  frequency  stands  the 
cardiac  orifice;  most  rarely  does  it  involve  the  whole  viscus.    We 

*  Quoted  in  British  and  Foreign  Medico-Chirurgical  Keview.  Feb.  1864; 
see,  also,  the  excellent  monograph  by  Krauss,  "Das  perforirende  Geschwiir 
im  Duodenum,"  18G5,  and  remarks  on  it  in  Niemeyer's  work  on  Practical 
Medicine,  and  Wadham  and  Barclay,  London  Lancet,  Feb.  and  March,  1871. 

■f  Walshe  on  Cancer. 


DISEASES    OF    THE    STOMACH.  477 

find  all  the  varieties  of  cancer  affecting  the  stomach ;  but  none 
is  so  common  as  scirrhus.  Indeed,  what  is  called  cancer  of  the 
stomach  means,  in  the  large  majority  of  cases,  scirrhus;  and,  more- 
over, scirrhus  at  the  pyloric  extremity,  deposited  primarily  in  the 
textures  which  intervene  between  the  mucous  and  the  serous  coat. 
It  would  be  out  of  place  to  enter  here  into  a  minute  description 
of  the  appearances  of  a  gastric  scirrhus.  I  shall  only  state  that  I 
have  usually  found  it  to  present  cell -growths  less  marked  than 
those  of  scirrhus  of  any  other  part  of  the  body. 

The  symptoms  of  cancer  of  the  stomach  are  the  same  as  of 
chronic  gastritis, — pain,  tenderness  in  the  epigastrium,  disordered 
digestion,  vomiting.  In  a  more  advanced  state  of  the  cancerous 
malady  they  may  be  those  of  gastric  ulcer,  hemorrhage  being 
added  to  the  list  above  given.  There  is  only  one  symptom  at  all 
distinctive  of  cancer, — namely,  the  existence  of  a  tumor ;  and  this 
is  so  only  when  it  is  joined  to  digestive  disorder  and  to  increasing 
anorexia,  debility,  and  emaciation. 

But  let  us  see  if  there  is  something  in  the  pain  and  vomiting, 
or  in  the  accompanying  circumstances  of  the  case,  by  which,  even 
when  a  tumor  cannot  be  discovered,  the  presence  of  a  cancer  may 
be  suspected.  Pain  is  a  very  constant  symptom ;  quite  as  constant 
as  in  gastric  ulcer.  But  the  pain  is,  as  a  rule,  more  continued, 
much  less  influenced  by  the  taking  of  food,  and  more  radiating, 
being  often  referred  to  the  right  or  the  left  hypochondrium.  Its 
character  is  very  varying.  It  may  be  dull,  or  gnawing,  or  it  may 
be  lancinating.  It  may  be  slight,  or  it  may  amouut  to  excruci- 
ating agony.  It  is  often  of  the  latter  kind.  But  it  is  a  mistake 
to  suppose  that  a  cancer  of  the  stomach  necessarily  causes  severe 
or  lancinating  pain.  Again,  it  should  be  borne  in  mind  that  the 
part  diseased  may  ulcerate,  and  then  the  pain  is  exactly  like  that 
of  an  ordinary  gastric  ulcer,  and  is  affected  in  the  same  way  by 
food. 

Vomiting  is  not  an  invariable  result  of  cancer;  yet  it  is  a 
frequent  one.  The  seat  of  the  morbid  growth  determines,  to  a 
great  extent,  the  occurrence  of  vomiting  and  the  period  at  which 
it  will  happen.  When  the  body  of  the  stomach  is  attacked,  and 
the  orifices  are  not  obstructed,  it  may  not  take  place  at  all ;  or, 
if  it  take  place,  it  is  within  a  brief  time  after  meals.  When  the 
disease  has  narrowed  the  cardiac  extremity,  vomiting  supervenes 


478  MEDICAL    DIAGNOSIS. 

almost  immediately ;  the  food  has  hardly  been  swallowed  before 
it  is  brought  up  again.  But  when,  as  is  much  more  common, 
the  pylorus  is  constricted,  the  food  is  not  thrown  off  until  it 
attempts  to  pass  through  into  the  intestine;  therefore  not  until  a 
considerable  time  after  meals. 

With  respect  to  the  character  of  the  substances  ejected,  this  too 
depends  on  the  seat  of  the  cancer,  and  the  time  at  which  the  vomit- 
ing arises.  If  it  ensue  several  hours  after  meals,  the  cast-off  matter 
consists  of  food  partly  digested,  partly  in  a  state  of  highly  acetous 
fermentation.  An  enormous  quantity  of  acid  material,  the  accumu- 
lation of  several  meals,  is  sometimes  brought  up  during  one  act  of 
emesis.  The  ejected  matter  may  be  intermingled  with  blood,  and 
have  a  blackish  or  reddish-brown,  "  coffee-ground"  appearance ; 
or  the  mucus  which  is  thrown  up  may  be  tinged  with  black  flakes. 
But  it  is  rare  that  any  considerable  amount  of  unmixed  blood  is 
vomited. 

Thus,  a  close  study  of  the  pain  and  vomiting  may  furnish  evi- 
dence by  which  the  existence  of  a  gastric  cancer  may  be  suspected. 
There  are  a  few  other  circumstances  which  would  strengthen  this 
suspicion :  one  of  these  is  the  intense  acidity  of  the  stomach,  with 
the  sour  eructations ;  another,  the  extreme  flatulency ;  another, 
the  fetid  breath,  for  although  fetor  of  the  breath  may  result  from 
putrefactive  changes  in  the  food  in  almost  any  form  of  gastric 
disorder,  it  is  perhaps  never  so  permanent  or  so  much  complained 
of  as  in  cancer.  A  fourth  is  the  obstinate  constipation ;  a  fifth, 
the  progressive  loss  of  flesh  and  the  cachectic  appearance  of  the 
patient,  who  is  pale  and  tired-looking,  or  has  a  complexion  slightly 
jaundiced,  or  whose  face  is  of  a  color  which  seems  to  have  arisen 
from  a  combination  of  the  hue  of  chlorosis  and  of  jaundice.  The 
supposed  characteristic  straw  color  of  cancer  is  not  often  met 
with ;  sometimes  we  observe  red  spots  on  the  cheek  in  the  after- 
noon. And  there  are  exceptional  cases  in  which  a  moderate 
amount  of  irritative  fever  accompanies  the  gradual  wasting, — 
gradual,  because  the  duration  of  the  malady  averages  fully  a  year. 

Now,  should  all  these  symptoms  be  met  with  in  a  person  who 
is  steadily  becoming  feebler,  whose  age  is  above  forty,  in  whose 
family  cancer  is  hereditary;  should  cancerous  tumors  develop 
themselves  in  any  other  part  of  the  body, — the  suspicion  enter- 
tained would   be  converted   into  almost  a  certainty.     But  it  is 


DISEASES    OF    THE    STOMACH. 


479 


not  often  that  a  perfectly  typical  case,  presenting  a  combination 
of  all  the  symptoms  enumerated,  is  met  with.  And  I  repeat, 
that  the  most  distinctive  sign  is  a  tumor :  when  this  is  not 
detected,  considerable  uncertainty  hangs  over  any  diagnosis  of 
gastric  cancer. 

To  contrast,  then,  cancer  of  the  stomach  with  chronic  gastritis 
and  gastric  ulcer : 


Chronic  Gastritis. 
Pain  at  the  epigastrium  some- 
what augmented  by  food ; 
also  soreness.  Both  con- 
stant, although  compara- 
tively slight. 


Symptoms  of  indigestion. 


Sometimes  vomiting. 

No  hemorrhage,  or  but  trifling 
hemorrhage ;  and  even  a  tri- 
fling hemorrhage  is  rare. 

Bowels  constipated. 

No  fever. 

Not  much  emaciation:  no  ca- 
chectic appearance. 


Not  confined  to  any  age.  More 
common  in  middle-aged  or 
elderly  people. 

Disease  may  be  relieved  or 
cured,  or  is  of  very  long 
duration. 

No  tumor. 


Gastric  Ulcer. 

Pain  at  the  epigastrium  much 
augmented  by  food ;  subsides 
when  this  is  digested  ;  parox- 
ysms of  pain,  but  not  lan- 
cinating; a  strictly  localized 
soreness  to  the  touch  in  the 
epigastric  region,  sometimes 
a  painful  spot  over  the  lower 
dorsal  vertebra?.  Intermis- 
sions in  the  pain  of  consider- 
able length  are  frequent. 

Symptoms  of  indigestion  some- 
times very  slight. 

Vomiting  may  be  present  or 

absent. 
Abundant  hemorrhage    from 

the  stomach  common. 

Bowels  may   or    may  not  be 

constipated ;  usually  are. 
No  fever. 

Frequently  extreme  pallor  and 
debility. 


May  occur  in  middle-aged  per- 
sons; but  is  also  frequently 
seen  in  young  adults,  espe- 
cially in  young  women. 

Duration  uncertain;  may  get 
well,  may  run  on  rapidly  to 
perforation ;  on  the  other 
hand,  may  last  for  years. 

No  tumor. 


Gastric  Cancer. 
Pain  frequently  of  a  radiating 
kind,  often  paroxysmal,  not 
unusually  severe  and  lanci- 
nating, but  not  of  necessity 
associated  with  soreness.  Lit- 
tle or  not  at  all  affected  by 
food.  Pain  rarely  remits ;  never 
intermits  for  any  considerable 
time. 


Symptoms  of  indigestion.  An- 
orexia; extreme  acidity  of 
stomach. 

Vomiting  a  very  frequent  symp- 
tom. 

Hemorrhage  not  very  abundant, 
but  occasioning  frequently  cof- 
fee-ground-looking vomit. 

Bowels  obstinately  constipated. 

Attacks  of  moderate  fever  may 
oecnr. 

Gradual  and  progressive  loss  of 
flesh,  and  debility ;  and  at  times 
with  the  cachexia  hypertrophy 
of  the  peripheral  lymphatic 
glands,  especially  above  the 
clavicles. 

Most  common  in  elderly  people  ; 
rarely  occurs  in  persons  under 
forty  years  of  age. 

Average  duration  one  year;  may 
be  shorter,  but  seldom  longer; 
very  rarely  reaches  two  years. 


Generally  a  tumor. 


The  differences  laid  down  in  the  table  are  derived  from  an 
analysis  of  well-marked  cases.  In  the  early  stages  of  the  cancerous 
malady,  a  differential  diagnosis  is  impossible.  Subsequently,  as 
already  stated,  the  detection  of  a  tumor  plays  an  important  part 
in  any  deduction.     But  this  remark  does  not  apply  to  cases  of 


480  MEDICAL    DIAGNOSIS. 

cancer  of  the  cardiac  orifice,  -which  are  rare,  and  in  which  a 
tumor,  from  its  deep  situation,  almost  always  eludes  discovery. 
Such  cases  are,  however,  discriminated  by  their  presenting  the 
same  signs  as  a  stricture  of  the  oesophagus  low  down ;  indeed,  they 
are  very  constantly  combined  with  a  narrowing  of  the  tube,  pro- 
duced by  the  cancer  spreading  to  it.  Cancer  at  other  parts  of  the 
organ  occasions  a  perceptible  tumor  in  about  three-fourths  of  all 
the  instances;  its  situation  is,  of  course,  not  always  the  same. 
Where  no  tumor  can  be  discerned,  and  particularly  if,  as  may 
"happen,  portions  of  the  stomach  remain  healthy  and  the  digestive 
disturbances  are  slight,  the  existence  of  cancer  mav  not  reveal 
itself  by  any  symptoms,  and  the  case  run  a  latent  course.* 

A  cancer  of  the  anterior  wall  produces,  as  a  rule,  fulness,  re- 
sistance, and  percussion  dulness  in  the  epigastric  region.  A  can- 
cer involving  the  greater  curvature  gives  rise  to  a  swelling  near 
the  umbilicus,  or  to  one  extending  toward  either  hvpochondrium. 
The  tumor  formed  by  cancer  of  the  pylorus  is  commonly  felt 
plainly  a  little  to  the  right  of  the  median  line,  and  one  to  two 
inches  below  the  cartilages  of  the  ribs.  In  women  its  position  is 
apt  to  be  even  lower  than  this ;  and,  indeed,  in  both  sexes  the 
situation  of  the  indurated  pylorus  is  very  variable.  It  may  be 
pushed  down  to  near  the  umbilicus ;  nay,  it  has  been  discerned 
near  the  anterior  superior  spinous  process  of  the  ilium.f  It  is 
rarely  found  in  the*  left  hvpochondrium,  but  not  unfrequently  in 
the  right.  Then  it  may  form  adhesions  to  the  liver,  which  viscus 
at  times  so  completely  covers  the  tumor  as  to  render  this  impossible 
of  detection. 

The  rea-on  why  the  swelling,  in  not  a  few  instances,  shows 
itself  much  lower  than  the  normal  seat  of  the  pylorus,  is  obvious. 
During  meal  after  meal  the  organ  seeks  to  overcome  the  resistance 
offered  by  the  narrowed  pyloric  orifice,  and  does  so  with  great  and 
increasing  difficulty.  The  constantly-repeated  and  long-continued 
struggle  leads  to  hypertrophy  of  the  muscular  coat  and  to  distention 
of  the  hollow  viscus. 

The  tumor  may  or  may  not  be  movable, — generally  is  not;  its 
surface  may  be  either  smooth  or  nodulated.     It  may  be  large  and 

*  See  report  of  case  under  my  care  at  the  Pennsylvania  Hospital,  published 
in  Amer.  Journ.  of  Med.  Sei.,  vol.  lii.,  1866. 
f  See  Lebert's  cases  in  Traite  pratique  des  Maladies  cancereuses. 


DISEASES    OF    THE    STOMACH.  481 

distinct,  or  small  and  requiring  a  careful  examination  to  distin- 
guish it  from  the  surrounding  and  more  yielding  textures.  Per- 
cussing over  it  elicits  a  dull  sound,  usually  mixed  with  a  tympanitic 
note.  The  tumor  is  much  more  perceptible  on  some  days  than  it 
is  on  others.  Its  existence,  as  has  been  already  insisted  on,  furnishes 
the  most  conclusive  evidence  in  favor  of  a  cancer. 

But  is  a  swelling  in  the  region  of  the  stomach  strictly  pathog- 
nomonic of  gastric  cancer  ?  No ;  not  even  when  the  swelling  has 
been  ascertained  to  belong  to  that  viscus.  A  mere  fibroid  thicken- 
ing of  the  pylorus  will  occasion  a  tumor,  and,  moreover,  produce 
symptoms  which  resemble  so  closely  those  of  malignant  disease  at 
the  orifice,  that  I  much  doubt  the  possibility  of  distinguishing 
during  life,  with  any  certainty,  between  the  two  affections.  Let 
us  take  this  case,  which  I  saw  with  Dr.  Moss,*  as  an  example. 

A  woman,  aged  forty,  complained  much  of  pain  at  the  pit  of 
the  stomach,  and  of  a  heavy  sensation  throughout  the  abdomen. 
For  some  months  she  had  been  suffering  from  indigestion,  and  had 
been  steadily  losing  flesh  and  strength.  Her  countenance  had  a 
tired  look,  and  she  was  very  despondent.  She  had  a  slight  cough ; 
and  on  percussing  the  lungs,  impaired  resonance  was  detected  at 
the  apices.  The  bowels  were  obstinately  constipated,  the  tongue 
was  smooth  and  red,  the  pulse  feeble.  She  vomited  shortly  after 
meals,  yet  never  anything  but  the  ingesta.  There  was  no  pain  on 
pressure  over  the  pylorus;  but  a  greater  resistance  to  the  finger 
than  usual  was  detected.  The  further  progress  of  the  complaint 
was  marked  by  the  most  incessant  vomiting,  only,  however,  after 
meals.  Hydrocyanic  acid,  creasote,  opiates,  were  given  in  vain  to 
arrest  it.  Once,  and  once  only,  did  it  cease  for  several  days ;  and 
then  without  apparent  cause.  As  the  case  drew  toward  its  fatal 
termination,  the  patient  was  much  troubled  with  acid  eructations, 
and  had  occasionally  slight  febrile  attacks.  The  distress  in  the 
epigastrium  increased  in  severity.  About  three  weeks  before  her 
death  she  was  seized  with  lancinating  pains  under  both  patellae, 
which  were  neither  relieved  nor  aggravated  by  pressure  or  motion. 
They  were  accompanied  by  pricking  sensations  and  numbness  in 
the  legs,  and  an  inability  to  walk.  The  pains  gradually  ceased, 
but  the  loss  of  motion  and  numbness  increased  from  day  to  day. 

*  Published  in  full  in  Proceedings  of  Path.  Soc.  of  Phila.,  vol.  i. 

31 


482  MEDICAL    DIAGNOSIS. 

She  died,  utterly  exhausted  by  the  abdominal  pains  and  the  inces- 
sant vomiting,  about  three  months  after  she  began  to  reject  her 
food.  On  post-mortem  examination,  tubercular  deposits  were 
found  at  the  apices  of  the  lungs.  The  abdominal  viscera  were 
healthy,  except  the  stomach ;  and  this,  too,  was  healthy,  save 
at  its  pyloric  orifice,  which  was  so  narrowed  that  the  tip  of  the 
little  finger  could  hardly  be  forced  into  it.  The  mucous  lining 
lay  in  folds,  but  on  dissection  was  found  to  be  perfectly  normal. 
At  the  pylorus,  but  only  there,  the  submucous  and  the  muscular 
coat  were  uniformly  thickened.  Examined  microscopically,  they 
contained  nothing  but  fibro-areolar  tissue,  spindle-shaped  fibre- 
cells,  and  very  distinct  organic  muscular  fibres. 

Now,  here  is  a  case  which  was  not  cancer;  yet  it  had  the  symp- 
toms of  cancer.  It  is  true  that  the  absence  of  blood  and  of  glairy 
mucus  in  the  matter  vomited,  and  the  indistinctness  of  the  swell- 
ing, in  spite  of  the  great  emaciation,  were  against  the  supposition 
of  cancer  of  the  pylorus.  Still,  no  inference  based  on  these  data 
alone  could  be  strictly  trusted,  since  every  cancer  is  not  associated 
with  the  vomit  of  coffee-ground  material,  or  of  glairy  mucus,  or 
with  a  palpable  tumor.  The  disease  was  combined  with  tuber- 
cular deposits  in  the  lung.  Nor  is  this  the  only  example  of  the 
combination  which  has  come  under  my  notice.  And  when  a  tu- 
bercular state  of  the  lung  has  been  fairly  made  out,  and  there 
exist  at  the  same  time  signs  of  pyloric  obstruction,  I  hazard  a 
diagnosis  that  this  is  not  of  a  cancerous  nature,  but  consists  simply 
of  an  increased  development  of  the  submucous  coat,  with  probably 
subsequent  hypertrophy  of  the  muscular  tunic. 

The  fibroid  thickening  may  extend  throughout  the  whole  stom- 
ach. Such  cases  differ  from  cancer  by  their  long  duration;  the 
absence  of  hemorrhage,  of  vomiting,  and  of  severe  pain ;  and  the 
more  uniform  gastric  swelling.  The  affection  is  sometimes  ob- 
served in  spirit-drinkers.  Its  discrimination  from  cancer  is  never 
a  certainty,  but  merely  a  matter  of  conjecture. 

There  is  yet  another  affection  similar  to  gastric  cancer,  namely, 
dilatation  of  the  stomach;  not  that  dilatation  which  occurs  so  con- 
stantly in  connection  with  obstruction  of  the  pylorus,  whether 
cancerous  or  fibroid,  but  that  which  is  met  with  independently  of 
this  structural  lesion.  It  occurs  from  weakening  of  the  muscular 
coats  produced  by  malnutrition  or  impaired  innervation,  and  has 


DISEASES    OF    THE    STOMACH.  483 

been  noticed  as  an  attendant  upon  ansemia  or  hysteria,  or  following 
fevers,  or  obstruction  of  the  upper  part  of  the  bowel,  or,  as  Bam- 
berger mentions,  dislocation  of  the  stomach  by  omental  hernias. 
The  chief  signs  are  the  rejection  of  food,  sometimes  in  large  quan- 
tities and  retained  for  days ;  fermented  and  vomited  matter  con- 
taining often  torulse  and  sarcinse;  extension  of  the  tympanitic 
note  of  the  gastric  region,  detected  by  percussion ;  a  splashing 
sound  when  the  patient  moves,  particularly  after  drinking;  the 
low  line  of  dulness  occasioned  by  fluids  in  the  distended  organ, 
and  the  change  of  the  dulness  with  the  position  of  the  patient; 
and  slowly  progressing  emaciation.  The  disease  is  apt  to  be  of 
long  duration,  and  one  of  the  chief  points  in  its  diagnosis  is  the 
absence  of  a  hard  swelling. 

There  are  other  diseases  than  those  of  the  stomach  which  may 
occasion  a  tumor  in  its  region,  and  are  thus  liable  to  be  mistaken 
for  gastric  cancer.  Prominent  among  these  are  enlargement  of 
the  liver  projecting  into  the  epigastrium,  tumors  of  the  omentum, 
and  diseases  of  the  pancreas  and  of  the  kidney.  Of  course,  the 
stomach  symptoms  proper  are  not  so  marked  in  these  affections, 
and  in  some  they  may  be  wholly  wanting ;  examination  of  the 
urine  and  due  regard  to  the  history  of  the  case  will  show  us  the 
truth  about  the  others ;  and,  after  all,  the  chief  way  of  preventing 
ourselves  from  falling  into  error  is  to  seek  in  any  case  of  supposed 
gastric  cancer  for  these  other  diseases,  and  to  see  if  their  chief 
symptoms  be  present. 

Resting  with  this  general  statement,  I  shall  not  take  up  the 
differential  diagnosis  of  all  the  many  affections  mentioned ;  es- 
pecially as  some  are  referred  to  when  treating  of  partial  abdominal 
enlargements  and  of  cancer  of  the  liver.  But  there  are  two  which 
may  be  here  specially  looked  at :  one  is  omental  cancer,  the  other 
kidney  affection  attended  with  marked  swelling,  such  as  in  hydro- 
nephrosis, pyonephrosis,  abscess,  hydatids,  and  morbid  growths. 

In  omental  cancer  there  is  far  less  dyspepsia,  hemorrhage  and 
coffee-ground  vomit  are  absent,  the  tumor  appears  to  occupy 
chiefly  the  site  of  the  greater  curvature,  and  the  swelling  is,  or 
soon  becomes,  more  generally  diffuse. 

In  the  kidney  affections  referred  to,  the  history  is  of  great 
importance,  and  we  include  in  this  history  the  passage  of  renal 
calculi  as  bearing  on  some  forms  of  kidney  enlargement,  especially 


484  MEDICAL    DIAGNOSIS. 

abscess  from  impaction  of  stones;  and  the  limits  of  the  mass, 
though  this  may  project  into  the  epigastrium,  will  scarcely  be 
those  of  a  gastric  cancer.  But  the  most  certain  safeguard  against 
error  is  careful  and  repeated  examination  of  the  urine. 


SECTION   II. 

DISEASES   OF   THE   INTESTINES   AND   OF   THE   PERITONEUM. 

In  considering  the  diseases  of  the  intestines,  we  meet  with 
symptoms  the  import  of  which  we  have  examined  in  connection 
with  affections  of  the  stomach.  We  encounter  nausea,  vomiting, 
and  derangement  of  the  powers  of  digestion.  These  disturbances 
are  to  a  great  extent  sympathetic,  or  else  dependent  upon  coexist- 
ing gastric  disorder ;  they  do  not  serve,  therefore,  as  trustworthy 
guides  in  the  detection  of  intestinal  maladies.  The  signs  upon 
which  we  rely  much  more  implicitly  are  pain  and  the  faecal  dis- 
charges. Now,  as  regards  the  former,  we  draw  the  truest  infer- 
ences, as  we  shall  presently  see,  from  its  kind  rather  than  from 
its  mere  occurrence.  The  study  of  the  faecal  discharges  tells  us 
often  in  a  more  direct  manner  what  is  going  on  in  the  long  tract 
of  intestinal  membrane. 

Alvine  Discharges. — To  examine  briefly  into  the  diversified 
appearances  of  the  stools : 

Watery  stools  are  observed  whenever  a  large  quantity  of  the 
serum  of  the  blood  finds  its  way  through  the  intestinal  coats. 
They  are  met  with  after  the  administration  of  saline  purgatives, 
in  serous  diarrhoea,  and  in  cholera.  Their  hue  varies :  they  may 
be  almost  colorless,  or  tinged  with  yellow.  Sometimes,  although 
very  thin  and  watery,  they  are  decidedly  yellow ;  again  they  are 
rendered  turbid  by  the  dissemination  of  whitish  flocculi  of  cast-off 
epithelium,  or  by  mucus.  Whether  they  be  yellow  or  colorless 
depends  on  the  existence  or  non-existence  in  them  of  faecal  matter 
and  of  bile.  In  a  prognostic  point  of  view,  the  most  colorless 
evacuations  are  the  most  dangerous.     Their  persistence  bespeaks 


DISEASES   OF    THE    INTESTINES    AND    PERITONEUM.        485 

a  continued  absence  of  healthy  faecal  matter  and  of  the  proper 
secretion  of  bile. 

The  presence  of  an  excessive  quantity  of  mucus  renders  the  dis- 
charges less  consistent  than  natural ;  yet,  unless  they  contain  more 
or  less  serum,  they  are  not  of  necessity  very  liquid.  Stools  with 
much  mucus  are  met  with  in  some  cases  of  diarrhoea  and  in  dysen- 
tery. The  appearance  they  present  is  similar  to  that  of  the  white 
of  an  egg;  or  the  whitish  masses  of  mucus  surround  the  lumps  of 
faeces,  or  are  intermingled  with  the  fluid  alvine  discharges. 

Pus  in  large  amount  and  unmixed  with  faeces  is  discharged  only 
when  an  abscess  has  ruptured  into  some  part  of  the  intestine. 
Stools  composed  of  faeces  and  pus  are  encountered  in  chronic 
inflammation  and  in  ulceration  of  the  bowels;  and  whitish, 
creamy  streaks  indicate  the  presence  of  the  foreign  substance. 
Yet  the  pus  may  be  so  intimately  blended  with  the  faeces,  or  with 
masses  of  mucus,  as  to  require  the  microscope  for  its  detection. 

Stools  consisting  entirely  of  bile  are  rarely  met  with.  More 
generally  there  are  other  elements  joined  to  the  voided  secretion 
of  the  liver.  An  excess  of  bile  in  the  alvine  discharges  gives 
rise  to  evacuations  of  a  yellowish-brown  or  yellow  hue,  which 
darkens  on  exposure  to  the  air.  When  the  alimentary  tube  is 
highly  acid,  the  resulting  color  is  green.  Both  these  kinds  of 
stools  are  commonly  called  "  bilious ;"  but  the  latter  is  perhaps 
less  absolutely  so  than  the  former.  A  deficiency  of  bile  manifests 
itself  by  clayey,  sometimes  even  by  almost  white,  stools. 

Black  stools  result  from  the  action  of  certain  medicines,  as  of 
iron ;  from  a  vitiated  condition  of  the  bile  and  intestinal  secre- 
tions, such  as  occurs  in  bilious  fever;  or  from  the  effusion  of  blood 
into  the  alimentary  canal.  At  all  events,  when  the  hemorrhage 
proceeds  from  the  stomach  or  the  upper  part  of  the  canal,  the  stools 
have  a  black,  tarry  appearance ;  when  from  the  lower  section  of 
the  tube,  pure  blood  is  passed,  or,  if  it  be  small  in  quantity,  a 
blood-streaked  mucus.  Should  any  doubt  exist  as  to  whether  the 
dark  discharges  be  dependent  upon  the  presence  of  blood,  let  them 
be  diluted  with  water ;  they  will  assume  a  reddish  tinge  if  this  be 
the  cause  of  the  abnormal  color. 

The  odor  of  the  evacuations  is  extremely  offensive  in  fevers  of 
a  low  type,  and  when  the  intestinal  secretions  are  vitiated.  So, 
too,  at  times  in  smallpox  and  in  cholera.     Acidity  of  the  intes- 


486  MEDICAL    DIAGNOSIS. 

tinal  canal,  as  in  the  diarrhoea  of  children,  or  in  rheumatism  or 
gout,  imparts  to  the  stools  a  sour  smell. 

In  cases  of  constipation  it  may  be  important  to  notice  the  shape 
of  the  passages,  because  this  may  show  whether  an  impediment  in 
the  gut  has  flattened  or  otherwise  altered  them.  In  fevers,  as 
well  as  in  affections  of  the  intestinal  mucous  membrane,  whether 
inflammatory  or  not,  we  often  derive  much  information  from 
studying  the  form  of  the  voided  matter.  Figured  stools  succeed- 
ing to  fluid  passages  are  always  of  favorable  omen. 

Chemical  and  microscopical  examinations  of  the  faeces  are  not 
often  made ;  yet  chemistry  and  the  microscope  may  be  frequently 
of  great  service.  They  enable  us,  for  instance,  to  recognize  with 
certainty  that  the  yellowish  lumps  contained  in  the  evacuation, 
or  the  greasy  film  which  collects  upon  its  surface,  consist  of  fat. 
The  microscope,  too,  detects  pus  and  blood ;  and  it  exhibits,  in 
the  fsecal  discharges  of  all  diseases  in  which  the  stools  readily  de- 
compose, masses  of  crystals  of  the  triple  phosphates,  and  in  typhoid 
fever  shreds  of  slough  from  the  enteric  ulcers.  One  drawback  to 
the  use  of  chemical  research  for  clinical  purposes  is  the  uncertain 
composition  of  the  faeces,  owing  to  the  number  of  elements  derived 
from  the  food.  A  further  objection,  both  to  it  and  to  microscop- 
ical investigation,  is  the  repugnance  every  one  feels  to  the  close 
examination  of  human  excrement. 

So  much  for  the  alvine  discharges.  Their  study,  it  is  evident, 
is  of  service  not  merely  in  intestinal  complaints,  but  equally  in  the 
many  maladies  in  which  the  alimentary  tube  sympathizes  or  be- 
comes involved.  But  to  return  to  the  uncomplicated  intestinal 
diseases,  grouping  them  as  they  may  be  recognized  by  pain  and 
peculiarity  in  the  fsecal  discharges,  and  describing  with  them,  for 
the  sake  of  convenience,  the  affections  of  the  peritoneum. 

Diseases  attended  with  Paroxysms  of  Pain  referred  chiefly  to 
the  Middle  or  Lower  Part  of  the  Abdomen,  and  not  asso- 
ciated with  marked  Tenderness  or  with  Fever. 

The  type  of  these  is  colic. 

Colic. — This  is  an  intestinal  pain,  paroxysmal  in  its  character, 
and  usually  combined  with  constipation,  but  unattended  with 
febrile  symptoms.     The  pain  is  of  a  severe  griping,  or  pinching, 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         487 

or  twisting  kind,  and  is  commonly  referred  to  the  neighborhood 
of  the  umbilicus.  It  is  generally  relieved,  or  at  any  rate  not 
aggravated,  by  pressure.  Yet  this  is  not  so  invariable  as  it  is 
ordinarily  held  to  be ;  for  sometimes  there  is  some  soreness  with 
the  pain,  and,  indeed,  a  slight  soreness  not  unfrequently  remains 
after  the  paroxysm  has  passed  off.  While  the  pain  lasts,  the 
countenance  wears  an  anxious,  frightened  expression  ;  the  skin  is 
cold,  or  covered  with  clammy  perspiration  ;  the  pulse  is  depressed. 
Occasionally  there  is  vomiting,  and  in  severe  cases  the  abdominal 
walls  are  tense  or  raised  in  hard  knots  by  the  spasmodic  contrac- 
tion of  the  muscles.  A  fit  may  last  only  a  few  minutes,  or,  with 
trifling  remissions,  for  several  hours. 

Some  persons  are  very  liable  to  attacks  of  colic.  Those  who 
suffer  from  indigestion,  or  are  enfeebled  by  exhausting  maladies, 
are  predisposed  to  them ;  so  also  are  hysterical,  gouty,  and  rheu- 
matic individuals.  As  to  the  exciting  causes,  they  are  various ; 
and  somewhat  according  to  its  different  causes,  colic  presents  dif- 
ferent forms.     Let  us  indicate  the  more  prominent. 

Colic,  simple  and  unconnected  with  a  disease  of  the  bowel. — Now, 
in  these  cases,  which  are  generally  called,  from  the  supposed  patho- 
logical condition,  spasmodic  colic,  the  paroxysmal  pain  may  have 
a  diverse  origin.  It  may  be  the  result  of  direct  excitation  of  the 
peripheral  intestinal  nerves  by  the  presence  of  irritating  substances 
in  the  alimentary  canal,  such  as  indigestible  food,  cold  or  acid 
drinks,  hardened  fasces,  gases,  morbid  secretions,  worms,  medi- 
cines, or  poisons.  It  may  proceed  from  an  irritation  of  the  cen- 
tral nervous  system  reflected  to,  and  manifesting  itself  in,  the 
intestinal  nerves.  It  may  be  sympathetic,  and  produced  by  a 
morbid  state  of  the  adjacent  abdominal  viscera,  at  times,  perhaps, 
through  the  intervention  of  the  central  nervous  system. 

1.  Colic  owing  to  food  difficult  of  digestion  is  very  common, 
especially  at  the  time  of  year  when  fruit  is  beginning  to  ripen. 
Sometimes  it  is  caused  by  food  which  is  not  in  itself  injurious, 
but  which  is  taken  in  quantities  greater  than  the  digestive  organs 
can  assimilate.  Hence  it  is  frequent  in  children  at  the  breast  who 
are  overnourished,  and  in  persons  in  delicate  health  with  enfeebled 
digestive  powers.  The  form  of  colic  under  discussion  is  often  at- 
tended with  vomiting  and  diarrhoea;  it  may  be  of  only  a  few 
hours'  duration,  or  it  may  last  for  several  days. 


488  MEDICAL    DIAGNOSIS. 

Colic  arising  from  distention  of  the  intestines  with  flatus,  or 
"flatulent  colic,"  is  the  result  of  the  decomposition  of  food  in  the 
alimentary  canal ;  sometimes,  however,  the  gases  are  extricated 
from  morbid  secretions,  or  are  exhaled  directly  from  the  blood- 
vessels. The  abdomen  is  very  tympanitic  and  greatly  distended, 
and  the  flatus  is  from  time  to  time  discharged  by  the  mouth  or 
by  the  anus,  with  evident  relief  to  the  patient.  Hysterical  persons 
are  very  subject  to  this  form  of  colic,  which  yields,  like  the  pre- 
ceding variety,  to  opiates,  purgatives,  and  warm  fomentations, 
and  to  the  administration  of  carminatives,  or  of  stimulating  in- 
jections. 

Colic  from  accumulation  of  hardened  fseces  is  preceded  by  obsti- 
nate constipation,  and  is  usually  a  tedious  disorder.  The  accessions 
of  pain  are  easily  enough  remedied  by  emptying  the  bowels;  but 
they  are  constantly  recurring. 

Colic  from  the  presence  of  morbid  secretions  in  the  intestinal 
canal  is  not  so  often  encountered  as  that  from  indigestible  food 
or  retained  faecal  masses.  Yet  it  is  occasionally  met  with  in 
eases  of  diarrhoea  attended  with  a  disordered  state  of  the  intestinal 
functions.  And  it  is  very  probable  that  even  in  the  so-termed 
bilious  colic  the  intestinal  pain  is  not  purely  sympathetic,  but  is 
owing  to  the  irritating  character  of  the  bile  discharged  into  the 
intestine. 

This  "  bilious  colic"  is  often  preceded  by  nausea,  loss  of  appe- 
tite, and  a  coated  tongue.  The  paroxysms  of  pain  frequently  go 
hand  in  hand  with  vomiting, — first  of  the  contents  of  the  stomach, 
then  of  bile.  They  are  in  general  accompanied  or  soon  followed 
by  a  yellowish  tinge  of  the  conjunctiva,  by  tenderness  in  the 
region  of  the  liver,  and  by  a  desire  to  go  to  stool.  The  bowels 
are,  however,  apt  to  be  obstinately  constipated.  Bilious  colic  is 
common  in  malarious  districts;  it  occurs  especially  during  the 
summer  and  autumnal  months,  and  frequently  follows  exposure. 
It  sometimes  begins  with  a  chill,  and,  unlike  the  other  forms  of 
colic,  it  has  as  companions  febrile  excitement,  and  a  full,  frequent 
pulse.     Malarial  colic  may  occur  in  an  epidemic  form.* 

2.  In  the  second  class  of  cases  to  which  allusion  has  been  made, 
colic  is  dependent  upon  some  abnormal  condition  affecting  pri- 

*  American  Journal  of  the  Medical  Sciences,  April,  1872. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         489 

rnarily  the  great  centres  of  innervation.  The  colic  arising  from 
fright,  from  anger;  that  happening  in  nervous  females  and  hypo- 
chondriac males;  perhaps  that  proceeding  from  sudden  exposure 
to  cold;  the  form  which  is  sometimes  seen  coexisting  with  neu- 
ralgic pains  in  other  parts  of  the  body, — in  short,  all  those  cases 
which  are  spoken  of  as  nervous  colic,  might  here  be  mentioned. 

The  attack  is  sudden,  and  not  commonly  of  long  duration ;  but 
it  is  very  apt  to  be  repeated,  and  requires,  besides  appropriate 
medicines,  strict  attention  to  diet  and  proper  exercise  for  its  pre- 
vention. 

The  so-termed  "  metallic  colics"  are  further  instances  of  colic 
produced  through  agents  which  act  primarily  on  the  general 
nervous  system.  This  is  at  any  rate  true  of  lead  colic.  Copper 
colic  is  not  a  purely  neuralgic  colic.  It  exhibits  paroxysms  of 
severe  pain  like  those  caused  by  the  poisonous  influence  of  lead ; 
but  it  is  attended  with  nausea,  vomiting,  diarrhoea,  tenesmus,  an 
abdomen  distended  and  tender  to  the  touch ;  in  other  words,  it  is 
rather  an  inflammation  of  the  intestine  with  colicky  pain,  than 
uncomplicated  colic.  Lead  colic,  on  the  other  hand,  is,  as  far  as 
is  known,  a  pure  colic ;  for  in  the  recorded  examinations  of  those 
who  have  died  of  the  disorder,  no  abnormal  appearances  were 
found  in  the  intestines.  The  distinguishing  marks  of  lead  colic 
are  the  bluish-gray  line  along  the  gums;  the  contracted  abdomen; 
the  obstinate  constipation ;  the  great  relief  usually  afforded  to  the 
pain  by  pressure ;  the  duration  of  the  pain ;  its  marked  and  ago- 
nizing exacerbations ;  and  the  history  of  the  case.  The  signs  of 
the  lead  poisoning  also  manifest  themselves  in  other  parts  of  the 
body,  as  will  be  elsewhere  more  specially  considered. 

3.  Affections  of  various  organs  may  give  rise  to  colic,  by  sym- 
pathy, and  generally  through  the  intervention  of  the  nervous 
system,  to  which  the  irritation  is  first  transferred,  and  from  which 
it  is  then  reflected.  Thus,  colic  is  a  not  uncommon  attendant  on 
morbid  states  of  the  kidneys,  liver,  bladder,  testicles,  uterus,  or 
ovaries,  and  on  disordered  menstruation.  Yet  we  must  not  forget 
that  the  pain,  although  spoken  of  as  colic,  is  often  not  strictly 
intestinal,  but  is  merely  a  pain  radiating  from  the  affected  organs 
themselves. 

Colic  arising  in  consequence  of  some  abnormal  state  of  the  bowel. 
— In  the  preceding  illustrations  of  colic,  the  disorder  was  viewed 


490  MEDICAL    DIAGNOSIS. 

as  occurring  in  a  healthy  bowel.  But  colic  may  have  only  the 
significance  of  a  symptom,  and  be  combined  with  an  altered 
structure  or  a  changed  position  of  the  intestine.  This  is  a  point 
to  which  sufficient  attention  is  not  generally  paid.  The  word  colic 
suggests,  to  the  minds  of  most,  a  paroxysmal  pain,  constipation, 
and  a  spasm  of  the  bowel.  Now,  without  discussing  whether  a 
true  spasm  be  a  necessary  attendant  on  the  paroxysmal  pain,  it  is 
certain  that  there  is  nothing  so  absolutely  peculiar  about  the  pain 
that  its  association  with  an  involuntary  muscular  contraction  of 
the  intestine  can  be  regarded  as  invariable.  We  meet,  indeed, 
with  colicky  pains,  undistinguishable  from  those  of  pure  colic, 
linked  to  an  organic  disease  of  the  bowel,  and  under  circumstances 
some  of  which  forbid  the  idea  of  a  spasm.  They  are  encountered 
in  dysentery ;  enteritis ;  hernia ;  ulceration ;  intussusception  ;  stran- 
gulation ;  twisting ;  strictures ;  distention, — in  fact,  in  the  most 
various  morbid  states  of  the  intestine.  And  colic  as  a  symptom 
can  be  discriminated,  as  far  as  the  pain  is  concerned,  from  colic 
as  an  idiopathic  disorder,  only  by  a  careful  study  of  the  history 
and  the  concomitant  phenomena  of  the  case.  In  several  of  the 
maladies  cited,  however,  the  more  transitory  nature  of  the  pain, — 
or  gripings,  as  they  are  termed, — in  others,  the  presence  of  fever 
and  of  tenderness,  serve  as  guides  in  diagnosis.  Fever  and  sore- 
ness to  the  touch  are  also  met  with  in  that  form  of  inflammation 
of  one  or  several  coats  of  the  bowel  which  happens  after  exposure 
or  after  the  retrocession  of  rheumatism  from  some  external  part, 
and  which  is  commonly  known  as  rheumatic  or  inflammatory 
colic. 

Having  thus  indicated  the  various  forms  of  colic,  and  having 
alluded  to  the  relation  they  bear  to  structural  diseases  of  the  in- 
testines and  to  affections  of  adjacent  viscera,  it  is  unnecessary  to 
re-examine  the  field  and  point  out  how  wide  its  extent  is  from  a 
diagnostic  point  of  view.  I  shall  only  here  again  insist  on  the 
necessity  of  tracing  out  in  every  case,  as  far  as  possible,  the  cause 
of  the  painful  malady,  so  as  to  know  if  any  serious  mischief  lie 
at  the  bottom  of  it;  and  shall  but  add  a  few  words  with  reference 
to  the  disorders  with  which  uncomplicated  colic,  or  that  which  is 
held  to  be  purely  spasmodic,  may  be  confounded.     They  are : 

Gastralgia  ; 

Perforation  of  the  Intestine; 


diseases  of  the  intestines  and  peritoneum.       491 

Strangulated  Hernia; 

Passage  of  Gall-stones; 

Nephralgia  ; 

Spasm  of  the  Bladder; 

Uterine  Colic; 

Neuralgia  of  the  Dorsal  and  Lumbar  Nerves; 

Abdominal  Aneurism  and  Tumors;  Diseases  of  the 
Spine  ; 

Enteritis  and  Peritonitis. 

Gastralgia. — In  gastralgia  or  gastrodynia  the  pain  is  seated  in 
the  epigastric  region ;  whereas  in  colic  it  is  either  in  the  neighbor- 
hood of  the  umbilicus,  or  rapidly  shifts  its  position  from  that  point 
to  different  parts  of  the  abdomen,  and  is  often  connected  with  a 
spasmodic  contraction  of  the  abdominal  muscles.  Again,  the  his- 
tory in  cases  of  gastralgia ;  the  fact  that  the  attacks  happen  most 
frequently  after  meals ;  their  association  with  signs  of  a  disordered 
stomach, — indicate  the  organ  in  which  the  pain  arises. 

And  much  the  same  general  signs,  in  addition  to  the  marked 
constipation  and  the  visible  movements,  enable  us  to  distinguish 
those  instances  of  peristaltic  disturbance  of  the  stomach  to  which 
Kussrnaul*  quite  recently  has  called  attention,  and  in  which  the 
drawing  pain  is  apt  to  be  referred  to  the  intestine ;  indeed,  the 
peristaltic  disorder  may  spread  to  it. 

Perforation  of  the  Intestine. — When  paroxysms  of  pain  have 
their  origin  in  perforation  of  the  intestine,  the  extreme  prostra- 
tion and  collapse  show  that  they  are  not  produced  by  a  harm- 
less disorder  like  colic.  Further,  the  abdominal  distress  is  in 
such  cases  preceded  by  symptoms  of  a  diseased  state  of  the  stomach 
or  the  intestines :  and  if  the  patient  live  sufficiently  long  after  the 
accident,  the  pain  is  followed  by  great  distention  of  the  abdomen 
and  extreme  tenderness, — in  fact,  by  the  signs  of  peritonitis. 
However,  the  differential  diagnosis  is  occasionally  very  diffi- 
cult. Especially  is  it  so  in  typhoid  fever;  for  in  this  affection 
colic  is  readily  induced,  or  perforation  of  the  intestine  may  be 
brought  on  by  very  slight  exciting  causes ;  and,  moreover,  peri- 
tonitis, so  several  excellent  observers  think,  may  occur  without 
perforation. 

*  Sammlung  Klinisclier  Vortrage,  ~No.  181,  June,  1880. 


492  MEDICAL    DIAGNOSIS. 

Strangulated  Hernia. — All  mechanical  obstructions  of  the  in- 
testine will  lead  to  paroxysms  of  intestinal  pain.  They  are  met 
with  in  cases  of  intussusception  and  of  ileus;  they  are  equally 
frequent  in  cases  of  strangulated  hernia.  In  all,  the  obstinate 
constipation  must  arouse  suspicion  regarding  the  true  nature 
of  the  complaint.  But  to  detect  a  hernia  a  local  examination  is 
required ;  and  a  careful  search  at  the  usual  seats  of  this  affection 
ought,  therefore,  to  be  made  in  every  instance  of  severe  or  pro- 
tracted colic.  Persons  have  lost  their  lives  in  consequence  of 
the  neglect,  until  too  late,  of  this  simple  precaution  against  disas- 
trous error. 

Passage  of  Gall-stones. — The  passage  of  a  gall-stone  is  gener- 
ally attended  with  paroxysms  of  intense  pain  which  are  readily 
mistaken  for  colic.  There  is,  as  a  rule,  the  same  absence  of  fever 
and  of  tenderness.  Indeed,  pressure  is  often  resorted  to  in  order 
to  mitigate  the  suffering,  and  thus  the  resemblance  to  colic  is 
heightened.  The  points  of  distinction  from  colic  are,  the  position 
of  the  pain  in  the  epigastric  region ;  its  sudden  beginning  and 
sudden  termination ;  the  severe  nausea  and  vomiting  attending 
the  attack ;  the  jaundice ;  and  the  voiding  of  gall-stones  with  the 
stools.  The  latter  sign,  however,  though  a  positive  one,  assists 
less  in  the  discrimination  of  the  disorder  than  would  appear  at 
first  sight;  partly  because  it  does  not  serve  as  a  means  of  indi- 
cating the  nature  of  the  affection  until  its  close,  partly  because 
the  stone  often  escapes  detection  in  the  fseces.  The  other  circum- 
stances have,  therefore,  a  more  available  diagnostic  value.  Yet 
even  they  do  not  enable  us  to  distinguish  positively  between  the 
transit  of  a  biliary  concretion  from  the  gall-bladder  to  the  intes- 
tine, and  the  bilious  colic  which  is  joined  to  derangement  of  the 
function  of  the  liver.  The  repetition  of  the  attack  is  always  a 
strong  reason  for  suspecting  it  to  be  owing  to  a  discharge  of  calculi 
from  the  gall-bladder;  and  so  are  severe  retching  and  vomiting, 
the  sudden  supervention  of  jaundice,  and  the  localized  epigastric 
pain.  But  these  phenomena,  too,  it  may  here  be  mentioned,  are 
produced  by  hepatic  neuralgia,  which  in  rare  cases  is  believed  to 
happen  independently  of  gall-stones.  And  there  is  nothing  by 
which  we  can  discriminate  this  malady — the  very  existence  of 
which  is,  indeed,  denied — except  its  recurrence  after  certain  inter- 
vals, the  alternations  with  other  affections  of  the  nervous  system, 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         493 

and  the  slightest  touching  of  the  part  inducing  at  times  the  acute 
pains.* 

Sometimes  gall-stones  are  closely  simulated  by  impacted  faeces, 
which  occasion  colicky  pains,  and  even  jaundice,  by  pressure. 
The  pain  is  at  once  removed  by  morphia  given  hypodermically, 
and  a  dose  of  oil  brings  away  the  hardened  faeces.  The  attacks 
may  recur,  and  are  always  relieved  in  the  same  manner.  The 
swelling  in  the  right  side  may  sometimes  be  readily  detected. 

Where  the  gall-stones  are  large  and  have  become  impacted  in 
their  course  toward  the  intestine,  they  give  rise  to  inflammation 
which  may  lead  to  ulceration  and  to  the  discharge  of  the  concre- 
tion— generally  then  very  large — into  the  intestine  or  stomach. 
Subsequently  an  obliteration  of  the  duct  may  happen ;  or  the  in- 
flammation and  ulceration  of  the  duct  may  result  in  perforation 
into  the  peritoneum.  In  some  cases  the  gall-stones  are  voided 
through  the  abdominal  walls,  in  consequence  of  their  having  caused 
inflammation  of  the  gall-bladder  and  subsequent  adhesions  to  the 
abdominal  parietes.  The  fistulous  passages  discharge  pus  and 
bile,  and  occasionally  fresh  concretions :  they  may  last  for  years ; 
but  in  time  they  generally  heal.  As  regards  the  other  forms  of 
fistulous  communications  alluded  to,  they  very  rarely  present  symp- 
toms so  peculiar  as  to  warrant  anything  like  a  certain  diagnosis.^ 

Nephralgia. — Paroxysms  of  pain  with  intervals  of  comparative 
ease  and  unassociated  with  fever  occur  in  nephralgia,  or  pain  of 
the  kidney,  and  are,  therefore,  often  mistaken  for  colic.  Now, 
nephralgia  is  generally,  although  not  invariably,  caused  by  the 
passage  of  a  calculus  through  the  ureter.  Its  symptoms,  besides 
the  pain,  are  numbness  of  the  thigh,  nausea  and  vomiting,  a  con- 
stant desire  to  make  water,  and  aching  and  drawing  up  of  the 
testicle.  The  patient,  as  in  colic,  is  restless,  and  seeks  relief  by 
frequently  changing  his  position.  The  pain  comes  on  suddenly, 
and  is  excruciating.  It  is  felt  in  the  loins,  usually  on  one  side, 
and  shoots  along  the  track  of  the  ureter  to  the  corresponding  hip 
and  thigh.  It  sometimes  extends  to  the  pelvis  or  toward  the 
umbilicus,  and  is  often  attended  with  tenderness  in  the  course  of 
the  ureter.     Occasionally  it  is  almost  exclusively  felt  at  the  hip. 

*  See  the  cases  of  Budd,  on  Diseases  of  the  Liver;   of  Andral,  Clinique 
Medicale,  tome  ii.  ;  and  of  Frerichs,  Diseases  of  the  Liver. 
f  See  a  collection  of  cases  by  Murchison,  Edinb.  Med.  Journ.,  July,  1857. 


494  MEDICAL    DIAGNOSIS. 

When  the  stone  reaches  the  bladder,  the  pain  ceases  as  abruptly 
as  it  began;  though  sometimes  there  is  still  discomfort  produced 
by  the  stone  interfering  with  the  act  of  micturition.  During  the 
attack  the  urine  is  passed  in  small  quantities  at  a  time.  It  is 
high-colored ;  sometimes  it  contains  a  little  blood.  If  it  be  col- 
lected,  and,  after  all  pain  has  disappeared,  be  carefully  examined, 
a  small,  hard  body  or  a  sandy  deposit  is  generally  detected,  and 
reveals  the  cause  of  the  past  anguish.  It  is  from  the  presence  of 
the  sandy  deposit  that  the  complaint  has  received  popularly  the 
name  of  a  fit  of  "  the  gravel." 

From  the  description  given,  it  will  be  seen  that  in  several 
respects  the  disorder  is  like  intestinal  colic.  The  seat  of  the  pain 
is  a  point  of  distinction ;  yet  in  neither  complaint  is  the  seat  en- 
tirely characteristic.  It  is  not  always  strictly  umbilical  in  colic; 
it  is  not  always  exactly  in  the  region  of  the  ureter  or  kidney  in 
nephralgia.  Of  more  importance  is  the  state  of  the  urinary 
functions,  which  are  comparatively  undisturbed  in  colic.  Again, 
the  numbness  of  the  thigh  and  the  retraction  of  the  testicle  are 
valuable  diagnostic  marks;  they  would  be  absolutely  decisive, 
were  they  constantly  present  in  nephralgia. 

Spasm  of  the  Bladder. — The  bladder  is  sometimes  the  site  of 
paroxysms  of  violent  pain,  supposed  always  to  attend  upon  a 
spasm  of  the  viscus.  There  is  an  intense  desire  to  urinate,  which 
the  passing  of  water  does  not  allay.  The  pain  is  not  steady;  it  has 
its  intervals  of  cessation.  It  is  accompanied  by  a  sense  of  con- 
striction at  or  near  the  pelvis,  and  sometimes  by  tenesmus,  and 
may  extend  to  the  kidneys,  to  the  thighs,  and  to  the  sacrum ;  or 
the  irritation  may  be  communicated  to  the  penis,  and  cause  erec- 
tions. If  the  sphincters  be  involved,  the  urine  cannot  be  voided. 
The  bladder  distends ;  there  is  intense  anxiety,  with  restlessness ; 
the  pulse  is  feeble ;  the  skin  is  cold,  and  covered  with  clammy 
perspiration. 

A  spasm  of  the  bladder  may  be  caused  by  the  presence  of  a 
stone,  or  of  irritating  urine  in  it.  It  is  also  encountered  in  gout 
and  hysteria,  and  as  the  result  of  stimulating  diuretics.  Violent 
fright,  too,  may  occasion  it.  It  sometimes  proceeds  from  a  dis- 
order of  adjacent  structures,  such  as  of  the  rectum,  or  of  the 
uterus.  Now  and  then,  as  Sir  Benjamin  Brodie  pointed  out,  it  is 
associated  with  inflammation  or  suppuration  of  the  kidney,  and 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         495 

the  vesical  pain  is  so  intense  that  it  withdraws  attention  from  the 
organ  most  affected.  To  distinguish  it  from  colic  is  not  difficult : 
the  position  of  the  pain  and  the  disturbed  condition  of  the  urinary 
functions  serve  as  guides.  It  resembles  more  closely  nephralgia, 
and  its  treatment  is  much  the  same  as  that  of  this  distressing 
complaint.  As  in  nephralgia,  too,  after  the  fit  is  relieved,  the 
important  indication  is  to  prevent  its  repetition  by  endeavoring 
to  remove  its  source. 

Uterine  Colic. — The  painful  sensations  experienced  by  some 
women  at  their  menstrual  periods  may  come  on  in  paroxysms 
similar  to  those  of  colic.  In  truth,  the  pain  is  often  spoken  of 
as  uterine  colic,  and  at  times  continues  for  many  days,  persisting 
during  the  whole  menstrual  period,  or  even  longer.  In  some  of 
these  cases  the  trouble  is  localized  in  the  uterus ;  in  others,  more 
especially  in  the  ovaries,  which  are  then  tender  to  the  touch. 
Similar  attacks  of  pain,  also  accompanied  by  congestion  or  even 
by  inflammation  of  the  ovaries,  are  occasionally  met  with  as  the 
result  of  falls  or  of  blows  on  the  hypogastric  region. 

Now,  with  reference  to  the  disorder  first  alluded  to,  or  ordinary 
dysmenorrhoea,  it  may  be  generally  easily  discriminated  from  colic 
by  its  concurrence  with  the  setting  in  of  the  menstrual  flow ;  by 
the  pain  remitting  rather  than  intermitting ;  by  the  seat  of  the 
pain  in  the  pelvis,  or  the  lower  part  of  the  abdomen ;  by  its  not 
uncommon  association  with  sickness,  nausea,  and  vomiting ;  and 
by  the  fact  that  all  the  signs  of  disordered  menstruation  have 
happened  over  and  over  again  at  the  menstrual  periods. 

Where  the  ovaries  are  very  much  congested  or  inflamed,  whether 
or  not  the  affection  exist  in  connection  with  dysmenorrhoea,  or 
occur  in  consequence  of  other  causes,  among  which  gonorrhoea 
may  be  one,  the  pain,  tenderness,  and  swelling  in  the  hypogastric 
region ;  the  not  unusual  numbness  and  flexed  position  of  one  or 
both  thighs ;  the  febrile  irritation,  and  the  hysterical  symptoms ; 
the  retention  of  the  urine  ;  the  violence  of  the  paroxysms  of  pain, 
and  the  duration  of  the  malady,  form  a  group  of  phenomena  very 
dissimilar  to  those  of  ordinary  cases  of  colic. 

Ovarian  neuralgia  has  symptoms  like  those  of  ovaritis,  but  is 
without  fever,  and  the  pain  is  apt  to  alternate  with  neuralgia 
elsewhere.     It  rarely  occurs  in  both  ovaries  at  once.* 

*  Clifford  Allbutt,  Liverpool  and  Manchester  Med.  Eep.,  1873. 


496  MEDICAL    DIAGNOSIS. 

Neuralgia  of  the  Dorsal  and  Lumbar  Nerves  ;  Abdominal  Neu- 
ralgia.— The  dorsal  and  lumbar  nerves  are  subject  to  neuralgic 
affections,  which  exhibit,  like  colic,  paroxysms  of  pain  unac- 
companied by  fever.  But  Yalleix  has  taught  us  to  look  for 
spots  painful  to  the  touch  in  the  course  of  the  aching  nerves,  and 
has  shown  that  the  disturbance  of  the  nerves  supplying  the  ab- 
dominal parietes  manifests  itself  on  one  side  of  the  body  only, 
whereas  an  irritation  of  the  intestinal  nerves  obeys  no  such  law. 

In  neuralgia  of  the  lumbar  nerves,  or  lumbo-abdominal  neural- 
gia, to  employ  the  term  sanctioned  by  Valleix,  the  pain  is  com- 
monly felt  in  the  hypogastric  region,  a  little  to  one  side  of  the 
median  line.  In  this  situation,  too,  there  is  localized  soreness  on 
pressure;  the  other  tender  spots  are,  generally,  one  a  little  to  the 
outside  of  the  first  or  second  lumbar  vertebra,  and  one  immedi- 
ately above  the  middle  of  the  crest  of  the  ilium.  In  women,  who 
are  by  far  the  greatest  sufferers  from  the  disease,  there  is  some- 
times also  a  painful  place  about  the  middle  of  the  Fallopian  tube, 
or  on  the  neck  of  the  uterus;  in  men,  a  point  on  the  scrotum  here 
and  there  is  found  sore  to  the  touch.  These  spots  of  tenderness 
serve  as  characteristic  signs ;  and  they  enable  us  to  separate 
neuralgia  not  only  from  colic,  but  also  from  lumbago,  and  from 
rheumatism  of  the  abdominal  walls. 

Besides  these  forms  of  neuralgia,  we  find  other  kinds  of  ab- 
dominal neuralgia,  which  may  be  mistaken  for  colic.  They  are 
attacks  of  pain  affecting  especially  the  mesenteric  plexus  or  the 
solar  plexus,  happening  in  paroxysms  of  great  severity,  and  at- 
tended with  a  sense  of  faintness  and  annihilation.  The  disorder 
is  unconnected  with  lead  poisoning  or  any  of  the  causes  which 
produce  colic,  is  often  excited  by  exertion,  and  is  associated  with 
debility  and  relieved  by  an  antineuralgic  treatment.  In  some 
cases  it  is  clearly  of  malarial  origin ;  and  in  every  case  we  must 
lay  great  stress  on  the  frequent  recurrence  of  the  pain  and  on  the 
history  to  enable  us  to  discriminate  between  the  neuralgic  com- 
plaint and  colic.  The  distinction  from  gastralgia  can  be  made 
only  by  the  more  marked  gastric  symptoms,  and  the  absence  of  or 
the  less  decided  prostration  and  sense  of  fainting  in  this  malady.* 

*  A  number  of  cases  of  abdominal  neuralgia  are  reported  by  Handfield 
Jones,  in  his  Treatise  on  Functional  Nervous  Disorders ;  and  by  Porcher, 
in  Amer.  Journ.  of  Med.  Sci.,  July,  1869. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         497 

Abdominal  Aneurism  and  Tumors;  Diseases  of  the  Spine. — In 
all  of  these  we  may  find  violent  pain  of  a  paroxysmal  kind  re- 
ferred to  various  portions  of  the  abdomen,  and  unaccompanied 
by  fever.  We  judge  that  the  pain  is  not  colic,  by  its  frequent 
repetition ;  by  its  want  of  association  with  intestinal  or  gastric 
disturbance;  by  its  being,  although  liable  to  exacerbations,  so 
steadily  present  at  some  part  either  of  the  spine  or  of  the  abdo- 
men ;  and  by  the  attending  symptoms  and  signs  occasioned  by  an 
abdominal  tumor,  or  by  a  disease  of  the  lower  dorsal  or  of  the 
lumbar  vertebrae. 

Enteritis  and  Peritonitis. — Inflammations  of  the  intestines  and 
of  the  peritoneum  also  give  rise  to  severe  abdominal  pain.  But 
it  is  more  constant,  linked  to  great  tenderness,  and,  in  acute  cases, 
to  symptoms  of  high  febrile  excitement.  Thus  enteritis  and  peri- 
tonitis belong  to  a  different  group  of  diseases, — a  group  of  in- 
flammatory affections,  which  I  shall  describe  somewhat  at  length, 
before  contrasting  the  symptoms  of  inflammation  of  the  intestines 
or  of  \he  peritoneum  with  those  of  colic. 

Diseases  attended  with  Pain  and  marked  Tenderness  in  the 
Umbilical  Kegion  or  diffused  over  the  Abdomen, 

Acute  Enteritis. — Enteritis  means  now,  by  common  consent, 
inflammation  of  the  small  intestine,  and  especially  of  the  portion 
that  lies  between  the  duodenum  and  the  colon.  The  morbid 
process  may  extend  to  the  colon ;  if,  however,  it  involve  a  large 
portion  of  the  latter,  it  is  colitis  or  dysentery,  and  not  enteritis, 
with  which  we  have  to  deal.  There  are  two  forms  of  enteritis; 
one  in  which  the  mucous  membrane  of  the  bowel  is  alone  affected; 
the  muco- enteritis,  or  the  catarrhal  inflammation  of  recent  authors, 
the  erythematous  enteritis  of  Cullen.  In  the  second,  more  than 
the  mucous  tunic  is  implicated ;  there  is  also  inflammation  of  the 
submucous  and  muscular  coats,  or  even  of  the  serous  investment 
of  the  bowel.  To  this  variety  of  the  complaint  the  term  enteritis 
is  by  several  writers  restricted ;  and  it  is  to  this  form  of  the 
malady,  occurring  acutely,  that  the  description  about  to  be  given 
more  particularly  applies. 

The  symptoms  of  an  acute  attack  of  enteritis  are  those  of  colic, 
attended  with  fever  and  tenderness.     The  disorder  may  begin 

32 


498  MEDICAL    DIAGNOSIS. 

with  the  symptoms  of  colic,  and  in  such  cases  the  inflammation 
of  the  bowel  is  said  to  have  supervened  on  colic;  or  it  may  set  in 
with  a  chill  and  fever,  and  extreme  thirst. 

When  the  disease  is  fully  established,  the  fever  runs  high ;  the 
pulse,  tense  and  full  at  the  onset,  becomes  small  and  wiry,  al- 
though it  remains  frequent.  There  are  nausea  and  vomiting,  and 
sometimes  most  distressing  fits  of  retching,  produced  either  by 
sympathy,  or  because  the  stomach  shares  in  the  inflammation. 
The  tongue  is  clean  and  of  natural  appearance,  or  it  is  covered 
with  a  white  coat,  or,  again,  it  may  be  red  and  dry.  The  bowels 
are  constipated ;  sometimes,  however,  there  is  diarrhoea,  or  con- 
stipation alternating  with  diarrhoea.  The  stools  are,  in  conse- 
quence, of  varying  consistency  and  color ;  they  may  contain  a 
small  quantity  of  blood,  but  they  very  rarely  contain  pus.  The 
appetite  is  completely  lost;  the  thirst  is  unceasing;  the  pain,  as 
in  colic,  is  paroxysmal.  It  begins  near  the  umbilicus,  and  thence 
may  shift  to  various  parts  of  the  abdomen,  but  not  to  the  epi- 
gastrium ;  yet  it  is  not  so  violent  nor  does  it  cease  so  entirely  as 
in  colic,  but  rather  exacerbates,  and  then  changes  to  a  dull  feeling 
of  distress.  It  is  greatly  increased  by  pressure,  and  the  patient 
seeks  relief,  as  in  peritonitis,  by  lying  on  his  back  with  his  thighs 
flexed,  so  as  to  relax  the  abdominal  muscles.  Toward  the  right 
of  the  umbilicus  it  is  not  uncommon  to  find  a  marked  pulsation, 
as  if  from  throbbing  of  the  abdominal  aorta  or  of  its  large 
branches, — a  sign  to  which,  if  I  mistake  not,  Stokes*  first  di- 
rected attention.  This  pulsation  may  be  very  annoying.  In 
looking  over  the  notes  of  cases  on  which  the  description  of  the 
symptoms  of  enteritis  just  given  is  based,  I  find  one  in  which 
neither  the  thirst,  nor  the  pain,  nor  the  nausea  and  vomiting  oc- 
casioned as  much  distress  as  the  violent  throbbing;  in  the  abdomen. 

In  those  instances  of  the  malady  which  advance  to  a  fatal  ter- 
mination, the  pulse  becomes  quick  and  irregular,  and  loses  its 
tenseness;  hiccough  appears;  the  abdomen  swells;  the  features 
are  haggard,  and  expressive  of  great  suffering;  and  the  patient's 
strength  becomes  gradually  exhausted.  The  worst  and  most 
hopeless  cases  of  the  disease  are  those  dependent  on  mechanical 
obstruction  of  the  bowel,  whether  it  proceed  from  organized  bands 

*  Article  " Enteritis,'1  in  Cyclopaedia  of  Practical  Medicine. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        499 

in  which  a  loop  of  intestine  is  caught,  or  from  invagination,  or 
from  accumulation  of  hardened  faeces,  or  from  a  hernial  stran- 
gulation. 

Among  the  symptoms  and  signs  of  enteritis  mentioned,  the 
pain  is  one  of  the  most  important  for  diagnosis.  It  is  never 
absent,  save  in  some  rare  instances  in  which  the  inflammation  is 
very  intense  at  the  onset.*  Still  more  important  is  the  great 
tenderness.  This  enables  us  to  say  that  the  case,  in  spite  of  the 
colicky  pains,  is  not  colic.  It  warns  us  not  to  resort  to  stimulants, 
and  to  remedies  merely  to  relieve  the  seemingly  spasmodic  pain. 
It  tells  us,  when  it  succeeds  to  what  began  as  ordinary  colic,  that 
inflammation  of  the  bowel  has  supervened  and  requires  immediate 
attention.  It  admonishes  us  not  to  administer  strong  cathartics 
to  overcome  the  constipation  which  appears  in  consequence  of  the 
severe  inflammation. 

The  disease  in  its  violent  form  just  described  bears  a  close  re- 
semblance to  peritonitis :  we  shall  presently  see  what  are  its  dis- 
tinguishing marks.  But  there  is,  as  above  stated,  another  variety 
of  the  disease,  a  mild  variety,  or  muco-enteritis,  in  which  the  dis- 
turbance is  limited  to  the  mucous  membrane.  The  main  features 
of  this  disorder  are  the  same,  but  they  stand  out  in  less  bold  relief. 
There  are  griping  pains,  a  slight  soreness  to  the  touch,  general 
uneasiness,  loss  of  appetite,  thirst,  nausea,  and  sometimes  vomit- 
ing. But  we  find  only  slight  fever;  or  rather,  the  skin  is  dry 
and  becomes  hot  toward  night,  and  the  febrile  excitement  remits 
in  the  morning.  Diarrhoea  is  always  present,  and  the  stools  are 
sometimes  very  offensive.  This  form  of  the  disease  may  termi- 
nate, as  the  severer  inflammation  generally  does,  in  less  than  a 
week ;  yet  it  may  persist  for  several  weeks,  and  thus  gradually 
lapse  into  a  chronic  complaint.  It  is  common  in  children,  espe- 
cially during  dentition.  It  is  also  observed  when  irritating  food 
or  secretions  occupy  the  alimentary  canal  for  any  length  of  time, 
or  after  exposure,  and  as  an  attendant  upon  the  exanthemata  and 
typhoid  fever.  Indeed,  it  is  sometimes  difficult,  particularly  in 
children,  to  know  whether  we  have  to  deal  with  a  case  of  muco- 
enteritis,  or  with  the  intestinal  complication  of  enteric  fever. 
The  state  of  the  cerebral  functions,  and  the  pain  and  gurgling  in 

*  Andral,  Pathologie  interne,  tome  i.  p.  47. 


500  MEDICAL   DIAGNOSIS. 

the  iliac  fossa,  may  clear  up  the  doubt ;  yet  in  some  cases  nothing 
but  the  eruption  and  the  course  of  the  symptoms  will  do  so. 

Another  affection  which  is  liable  to  be  mistaken  both  for  en- 
teritis and  for  typhoid  fever  has  been  recently  described.*  The 
chief  symptoms  are  violent  pains  in  the  hypogastric  region,  with 
vomiting,  thready,  frequent  pulse,  high  temperature,  and  the  rapid 
supervention  of  somnolence  and  coma.  In  some  instances  hemor- 
rhages happen.  Hemorrhagic  erosions  are  found  in  the  stomach, 
and  bloody  infiltrations  in  the  jejunum;  the  parenchyma  of  the 
mesenteric  glands,  their  lymphatics,  and  the  thoracic  duct  are  in- 
filtrated with  blood;  the  spleen  is  enlarged.  The  disorder  shows 
then  a  striking  hemorrhagic  tendency,  and  is  supposed  to  be  a 
blood-affection  similar  to  pseudoleukemia. 

Acute  Peritonitis. — As  in  acute  enteritis,  so  in  acute  peri- 
tonitis, pain  and  tenderness  are  the  most  significant  symptoms. 
To  these  are  joined  fever,  distention  of  the  abdomen,  and,  fre- 
quently, cold  sweats,  nausea,  vomiting,  and  obstinate  coustipation. 

Now  in  acute  peritonitis,  especially  in  the  form  in  which  the 
inflammation  has  involved  the  whole  membrane  or  a  large  part 
of  it,  the  disease  begins  with  chilly  sensations  or  protracted  rigor. 
To  these  succeed  fever,  abdominal  pain  and  distention.  The 
fever  runs  high  at  the  onset;  it  exhibits  a  dry,  burning  skin,  a 
high  axillary  temperature,  a  pulse  frequent,  but,  as  in  acute  inflam- 
mations of  the  mucous  and  serous  membranes  below  the  diaphragm, 
small  and  wiry.  However,  both  the  character  of  the  pulse  and 
of  the  skin  change  as  the  malady  progresses.  The  pulse  will  be 
less  tense  and  more  developed  as  the  inflammation  subsides,  or 
feeble  and  flickering  if  the  disorder  proceed  toward  a 'fatal  termi- 
nation. The  skin  is  frequently  covered  with  cold  sweats ;  the 
extremities  become  cool.  The  temperature  is  irregular,  and  may 
sink  below  the  normal.  The  features  are  sharpened  and  wear 
the  look  of  death,  even  in  cases  which  ultimately  recover. 

The  pain  is  constant  and  severe.  It  may  exacerbate,  but  it 
never  intermits.  At  first  the  pain  is  confined  to  a  particular 
point;  but  as  the  inflammation  extends,  so  it  extends  over  the 
whole  abdomen.  It  is  increased  by  the  slightest  pressure,  be  that 
pressure  exerted  by  the  hand  or  by  movements  of  any  kind.     To 

*  Klob,  "Wien.  Med.  Zeitung,  quoted  in  London  Med.  Record,  Feb.  18T5. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        501 

obviate  the  pressure,  the  patient  lies  on  his  back  with  his  thighs 
flexed,  and,  however  tired  of  retaining  the  same  position,  he  does 
not  change  it.  The  descent  of  the  diaphragm  augments  the  pain: 
instinctively,  therefore,  he  refrains  from  drawing  long  breaths, 
and  his  respiration  is  short  and  frequent.  If  closely  watched,  it 
is  found  to  be  purely  thoracic,  the  abdominal  walls  neither  rising 
nor  falling  during  the  respiratory  acts. 

The  abdominal  distention  is  in  part  owing  to  meteorism,  in  part 
to  the  liquid  effused  into  the  peritoneum.  Percussion  tells  us  in 
individual  cases  how  far  each  factor  acts  as  a  cause  of  the  enlarge- 
ment, by  the  tympanitic  or  the  dull  sound  elicited.  Palpation, 
too,  reveals  the  presence  of  liquid.  Yet  neither  percussion  nor 
palpation  ought  to  be  employed,  save  when  really  necessary  for 
diagnosis,  and  then  only  with  the  greatest  care,  on  account  of  the 
pain  they  occasion.  The  fluid  does  not  gravitate  as  invariably  as 
in  ascites  to  the  lower  portion  of  the  belly.  It  is  often  caught 
in  sacs  formed  by  the  membrane  adhering  in  spots ;  and  thus 
circumscribed  dulness  may  be  found  at  one  or  several  parts  of  the 
abdomen.  Sometimes  the  roughening  of  the  membrane  gives  rise 
to  a  distinct  friction  sound. 

Independently  of  the  abdominal  pain  and  swelling,  we  meet,  in 
acute  peritonitis,  with  constipation,  nausea  and  vomiting,  head- 
ache, a  suppression  of  the  urinary  discharge,  and  in  rare  instances 
with  priapism ;  of  these  symptoms,  constipation  is  the  most  con- 
stant. The  bowels  are  never  relaxed,  except  in  the  puerperal 
form  of  the  malady.  The  constipation  is  caused  by  the  paralyzed 
state  of  the  intestine,  to  portions  of  which  the  inflammation  may 
spread;  or  by  the  lymph  gluing  together  the  coils  of  the  bowels, 
and  thus  interfering  with  their  peristaltic  action. 

Death  in  acute  peritonitis  is  commonly  preceded  by  enormous 
tumefaction  of  the  belly,  cold  sweats,  a  pinched  countenance,  and  a 
rapid,  flickering  pulse.  When  recovery  takes  place — unfortunately 
a  rarer  issue  of  the  malady  than  its  fatal  termination — it  is  com- 
monly very  slow  and  gradual :  the  symptoms  diminish  one  by 
one;  they  do  not  cease  suddenly;  and  often  morbid  conditions 
remain  which  prolong  greatly  the  patient's  illness,  and  may  lead 
in  themselves  to  a  disastrous  result.  It  is,  therefore,  impossible 
to  foretell  the  duration  either  of  the  acute  disease  or  of  its  con- 
sequences.    Andral  fixes  the  average  length  of  an  acute  attack  at 


502  MEDICAL    DIAGNOSIS. 

between  six  and  nine  days,  and  of  a  subacute  attack  at  from 
twenty  to  thirty  days.  But  the  nature  of  the  malady  is  such  that 
many  cases  last  a  longer,  many  a  much  shorter  period. 

Acute  peritonitis  arises  occasionally  from  exposure  to  cold  and 
wet;  much  oftener  in  consequence  of  injuries  to  the  abdomen, 
such  as  blows,  stabs,  or  kicks ;  or  from  perforation  or  laceration 
of  some  of  the  abdominal  organs  and  discharge  of  their  contents 
into  the  peritoneal  cavity.  Uterine  injections  passing  into  the 
peritoneal  cavity  may  cause  peritonitis.  It  also  results  from  rheu- 
matism,* or  from  some  peculiar  and  poisoned  state  of  the  blood, 
as,  for  example,  that  frightful  form  of  peritonitis  occurring  in 
childbed  fever.  It  sometimes  originates  from  an  inflammation 
of  the  abdominal  viscera,  especially  of  the  spleen,  intestines,  or 
uterus  and  its  appendages,  spreading  to  their  serous  covering, 
and  thence  extending  more  or  less  rapidly.  Again,  other  morbid 
states  of  the  abdominal  organs,  such  as  cysts  of  the  ovaries,  in- 
testinal intussusception,  or  strangulated  hernia,  may  compress  or 
irritate  the  membrane,  and  lead  to  inflammatory  action.  Owing 
to  these  diverse  sources,  peritonitis  presents  varieties  which  exhibit 
points  of  difference  sufficient  to  require  special  notice. 

The  inflammation  produced  by  extravasation  into  the  peritoneal 
sac  is  characterized  by  its  sudden  development.  The  matters  ex- 
travasated  may  be  blood,  or  bile,  or  urine,  or  the  contents  of  the 
stomach.  Most  frequently  perforation  of  the  stomach  or  intestine 
lies  at  the  bottom  of  the  mischief.  Whatever  its  cause,  the  per- 
foration is  immediately  followed  by  collapse;  and  tenderness  and 
distention  of  the  abdomen  soon  make  their  appearance.  Yet 
peritonitis  may  set  in  rapidly  in  cases  in  which  there  has  been  no 
rupture;  and,  on  the  other  hand,  in  rare,  very  rare  instances,  the 
contents  of  the  alimentary  canal  may  be  discharged  into  the  sac 
without  giving  rise  to  inflammation. f 

The  peritonitis  of  childbed  fever,  or  puerperal  peritonitis,  is 
principally  distinguished  by  its  occurring  during  the  puerperal 
state.  Its  symptoms  are,  so  far  as  the  peritoneal  inflammation 
is  concerned,  those  of  any  other  kind  of  peritonitis,  except  that 

*  Schmidt's  Jahrbucher,  No.  9,  1873. 

j  Cases  reported  by  Bardeleben  and  Siebert,  quoted  in  Henoch's  Clinic  of 
Abdominal  Diseases.  Instances  of  rapid  peritonitis  without  perforation  are 
given  by  Thirial,  L'Union  Medicale,  1853. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        503 

diarrhoea,  instead  of  constipation,  is  commonly  present.  The  tem- 
perature rises  speedily  to  a  considerable  height,  and  continues  high 
with  irregular  remissions.  The  uterus  or  the  uterine  appendages 
are  generally,  but  not  invariably,  first  attacked ;  and  it  is  in  these 
regions  that  pain  and  tenderness  are  first  felt.  The  inflammation 
spreads  to  their  serous  investment,  or  it  may  be  primarily  seated 
in  that  investment:  in  either  case  it  soon  involves  the  entire 
membrane. 

But,  independently  of  the  symptoms  of  the  local  disorder,  there 
are  phenomena  which  clearly  belong  to  the  general  puerperal  dis- 
ease, of  which  the  inflammation  of  the  peritoneum  is  but  a  local 
expression ;  there  are  evidences  of  a  poisoned  state  of  the  blood  and 
of  a  general  disturbance  of  the  system.  How  else  can  we  account 
for  the  exudations  into  the  pericardium  and  pleura  being  like 
those  on  the  peritoneum?  How  else  can  we  account  for  the  black 
vomit,  and  for  the  delirium, — symptoms  far  from  seldom  met 
with  in  puerperal  peritonitis,  but  not  in  the  purely  local  disease? 
How  else  can  we  account  for  the  uniform  type  exhibited  by  the 
malady  in  some  epidemics,  and  its  varied  form  in  others  ? 

What  the  poison  is  which  determines  the  terrible  disease,  we 
cannot  here  inquire.  It  may  be,  as  some  think,  atmospheric;  it 
may  be,  as  others  hold,  septic,  from  the  absorption  of  putrid 
matter  from  the  uterus ;  it  may  be  an  animal  virus  transmitted  by 
the  hand  o£the  attendant;  the  complaint  may  be,  as  many  believe, 
closely  analogous  to  erysipelatous  inflammation ;  it  may  be  emi- 
nently contagious;  it  may  not  be  so  at  all.  These  are  not  points, 
however  important  their  solution  to  the  well-being  of  thousands 
of  lying-in  women,  which  concern  us  here.  For  diagnostic  pur- 
poses, it  is  of  more  consequence  to  know  that  the  distemper  pre- 
vails epidemically  and  endemically,  that  its  features  change,  and 
that  the  puerperal  peritonitis  of  one  year  is  not  the  puerperal 
peritonitis  of  another;  in  short,  that  while  childbed  fever,  what- 
ever its  cause,  occasions  peritonitis,  peritonitis  does  not  constitute 
childbed  fever. 

Taking  this  view  of  the  disease,  it  is  obvious  that  those  sporadic 
cases  of  peritonitis  occasionally  encountered  after  delivery,  in 
which  the  inflammation  has  either  become  general  or  remains 
limited  to  the  womb  and  its  surroundings,  are  very  different  from 
the  pestilential    disorder  which    attacks   numbers  of  parturient 


504  MEDICAL    DIAGNOSIS. 

females  simultaneously,  or  in  rapid  succession.  And  the  inference 
from  these  statements  is,  that  under  the  general  name  of  puerperal 
peritonitis  are  grouped  together  several  forms  of  peritoneal  inflam- 
mation, having  not  one,  but  several  causes,  accompanying  not  the 
same,  but  divers  constitutional  states,  and  presenting  not  always 
identical,  but  at  times  most  opposite  indications  for  treatment. 

Partial  or  local  peritonitis  is  almost  invariably  owing  to  a  pre- 
existing: morbid  condition  of  some  abdominal  viscus.  Sometimes 
the  circumscribed  inflammation  is  protective  rather  than  calculated 
to  work  mischief.  It  arrests  a  destructive  perforation  of  the  mem- 
brane, or  it  limits  the  matter  discharged  to  a  certain  spot;  it  may 
at  least  do  so  for  a  time,  for  general  peritonitis  is  very  apt  ulti- 
mately to  follow. 

Partial  peritonitis  often  pursues  a  subacute  rather  than  an  acute 
course.  It  may  end  in  adhesions  or  lapse  into  a  chronic  state.  Its 
symptoms  are  much  the  same  as  those  of  a  more  general  inflam- 
mation,— the  same  fever  and  constipation,  the  same  pain  and  ten- 
derness. The  fever  does  not,  however,  run  so  high,  and  the  pain 
and  the  great  tenderness  are  much  more  localized.  The  abdomen, 
also,  is  not  so  swollen  nor  so  tympanitic.  But  perhaps  even  more 
frequently  than  in  general  peritonitis  are  found  accurately  limited 
spots  of  dulness  on  percussion  corresponding  to  circumscribed 
collections  of  pus  in  the  peritoneal  cavity. 

Partial  peritonitis  is  more  liable  than  the  general  disease  to  be 
confounded  with  other  disorders.  Yet  error  can  hardly  arise,  or, 
should  it  arise,  it  is  not  of  much  consequence,  provided  we  bear 
in  mind  that  it  is  precisely  with  the  morbid  states  of  the  viscera 
which  lie  below  the  peritoneum  that  the  circumscribed  inflamma- 
tion of  the  serous  membrane  is  usually  connected,  and  that  local 
peritonitis,  therefore,  frequently  attends  the  very  disorders  from 
which  it  is  sought  to  be  distinguished.  Let  us,  however,  examine 
into  some  of  the  complaints  with  which  peritonitis,  whether  local 
or  general,  may  be  confounded.  They  are — leaving  for  considera- 
tion elsewhere  typhlitis  and  perityphlitis — 

Gastritis  ; 

Enteritis  ; 

Metritis  ; 

Cystitis  and  Distention  of  the  Bladder; 

Rheumatism  of  the  Abdominal  Walls; 


diseases  op  the  intestines  and  peritoneum.      505 

Abdominal  Hysteria; 

Colic. 

Gastritis. — Acute  inflammation  of  the  stomach  can  scarcely  be 
mistaken  for  inflammation  of  the  peritoneum,  provided  attention 
be  paid  to  the  history  of  the  case  and  the  seat  of  the  pain.  The 
former  disorder  begins  with  vomiting,  and  this  continues  a  promi- 
nent symptom  throughout ;  whereas  vomiting  is  neither  so  con- 
stant, nor  does  it  occur  so  early,  in  peritonitis.  The  pain  and 
tenderness  are  limited  to  the  region  of  the  stomach  in  gastritis; 
they  are  diffused  and  accompanied  by  general  abdominal  enlarge- 
ment in  peritonitis.  They  may,  it  is  true,  be  localized  when  the 
peritonitis  is  partial.  But  acute  inflammation  of  the  gastric  peri- 
toneum is  hardly  encountered,  save  as  an  attendant  on  severe  in- 
flammation of  the  stomach,  or  on  a  destruction  of  its  coats.  And 
in  the  first  instance  it  is  practically  gastritis  we  are  dealing  with ; 
in  the  second,  the  history  of  the  case,  the  sudden  increase  of  the 
pain  and  tenderness,  and  the  development  of  fever  will  go  far 
toward  evincing  the  nature  of  the  affection.  However,  if  a  partial 
peritonitis  occurring  in  consequence  of  serious  gastric  disease  be 
subacute  or  chronic,  it  eludes  discovery. 

Enteritis. — Enteritis  differs  from  general  peritonitis  by  the  less 
extended  tenderness ;  by  the  seat  of  the  pain  near  the  umbilicus, 
and  its  more  paroxysmal  character ;  by  the  comparative  absence 
of  tympanites  and  abdominal  tumefaction ;  and  by  the  greater 
prominence  of  nausea  and  vomiting.  It  is,  moreover,  a  disease 
far  less  violent  and  dangerous  than  acute  peritonitis ;  yet  it  can- 
not be  distinguished  with  certainty  from  the  partial  form  of  this 
disorder.  In  -truth,  as  far  as  the  diagnosis  of  enteritis  is  con- 
cerned, it  is  not  of  much  importance  that  it  should  be;  for 
inflammation  of  the  intestine  is  generally  associated  with  a  local 
peritonitis,  to  which  some  of  its  symptoms  are  clearly  owing. 

Metritis. — Inflammation  of  the  womb  is  not  likely  to  be  mis- 
taken for  general  peritonitis ;  the  pain  on  pressure,  which  they 
have  in  common,  is  confined  in  the  former  disease  to  the  uterus 
and  its  annexes,  and  there  is  little  or  no  tympanites.  It  is  thus, 
and  thus  only,  that  the  acute  metritis  of  childbed  fever  may 
be  distinguished  from  the  acute  general  peritonitis  of  the  same 
malady.  For  otherwise  the  resemblance  is  strong :  in  both,  the 
disease  is  ushered  in  by  chills,  and  the  lochial  discharge  soon 


506  MEDICAL    DIAGNOSIS. 

diminishes  or  ceases.  When  the  puerperal  malady  attacks,  as  it 
often  does,  the  uterus  as  well  as  the  whole  peritoneal  surface, 
the  signs  of  inflammation  of  the  serous  membrane  mask  those  of 
inflammation  of  the  womb. 

Now,  a  local  inflammation  of  the  peritoneum  occurs  still  more 
constantly  as  an  attendant  on  inflammation  of  the  womb  and  its 
appendages,  whether  the  disorder  of  the  sexual  organs  be  or  be 
not  puerperal.  It  frequently  leads  to  collections  of  pus,  which  can 
be  readily  felt  through  the  parietes  of  the  abdomen  or  through 
the  rectum  and  the  vagina,  and  which  sometimes  discharge  into 
the  bowel  or  vagina  after  a  lingering  sickness.  The  proofs  that 
the  uterus  is  involved  in  these  cases  of  partial  peritonitis,  are  the 
signs  of  its  disordered  functions  and  the  excessive  pain  occasioned 
by  pressing  on  the  cervix  during  an  examination  per  vaginam. 

Cystitis  and  Distention  of  the  Bladder. — Both  inflammation  and 
distention  of  the  bladder  are  occasionally  mistaken  for  general 
acute  peritonitis.  An  acute  inflammation  of  the  bladder  gives 
rise  to  frequent  calls  to  pass  urine :  yet  the  act  is  performed  with 
great  difficulty,  and  in  severe  cases  may  become  impossible;  the 
bladder  distends ;  a  sense  of  uneasiness  is  felt  in  the  perineum ; 
the  region  above  the  pubes  becomes  tender  to  the  touch,  and 
sounds  dull  on  percussion ;  the  unhappy  sufferer  is  very  restless 
and  distressed ;  he  has  the  excited  pulse  and  the  hot  skin  of  an 
inflammatory  fever;  at  times  vomiting  and  hiccough  supervene; 
and  death  is  preceded  by  gradually  deepening  coma.  Such  cases 
resemble  in  some  respects  those  of  peritonitis  with  suppression  of 
the  urinary  discharge  and  with  strangury.  But  the  urine  which 
is  voided  in  peritonitis  is  simply  high-colored,  like  that  of  any 
febrile  state.  In  cystitis  it  contains  large  quantities  of  mucus  and 
pus,  and  often  blood  and  crystals  of  phosphates.  Again,  the  ab- 
dominal tenderness  is  localized,  and  is  frequently  accompanied  by 
a  smarting  in  the  course  of  the  urethra.  Neither  of  these  signs  is 
encountered  in  peritoneal  inflammation.  The  disturbance  of  the 
urinary  organs  which  not  unfrequently  takes  place  in  the  latter 
disorder  has  been  attributed  to  inflammation  of  the  part  of  the 
peritoneum  covering  the  bladder  or  its  immediate  neighborhood. 
But  whether  it  be  so  or  not,  is  as  uncertain  as  Avhether  it  be  an 
inflammation  of  the  serous  investment  of  the  stomach  which  oc- 
casions the  nausea  and  vomiting  of  the  same  disease. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        507 

An  overdistention  of  the  bladder,  not  the  result  of  inflamma- 
tion of  its  coats,  may  produce  a  local  tenderness  spread  over  a 
considerable  portion  of  the  lower  part  of  the  abdomen.  But  the 
outline  of  the  dulness,  which  is  coextensive  with  that  of  the  ten- 
derness, the  fact  that  the  patient  has  generally  not  passed  urine 
for  a  considerable  time,  and  the  sudden  cessation  of  the  supposed 
peritonitis  on  passing  a  catheter,  show  the  true  nature  of  the 
malady.* 

Inflammation  and  Abscess  in  the  Abdominal  Muscles. — When 
the  abdominal  walls  become  inflamed,  symptoms  are  occasioned 
which  are  not  always  easily  distinguished  from  those  of  acute 
peritonitis.  The  disease  is  attended  with  some  fever,  with  pain 
increased  by  movement,  by  the  act  of  coughing,  and  by  pressure, 
and  sometimes  with  excessive  tenderness.  The  seat  of  the  inflam- 
mation is  generally  the  rectus  muscle  and  the  surrounding  cellular 
tissue.  The  parts  on  one  side  of  the  umbilicus  are  most  commonly 
attacked,  and  it  is  there  that  a  hard  swelling  is  perceived,  over 
which  the  skin  is  rather  hot  and  sometimes  red.  The  tumefaction 
gradually  disappears  by  resolution,  or  else  "fluctuation  becomes, 
from  day  to  day,  more  distinct,  showing  that  suppuration  is 
taking  place;  and  the  pus  being  discharged,  immediate  relief 
follows,  and  the  pain  and  febrile  symptoms  instantly  cease. 

Now,  the  disease  rarely  runs  a  very  acute  course;  it  lasts  at 
least  a  week  or  two,  and  often  much  longer.  Where  much  of  the 
muscle  is  involved,  the  complaint  closely  simulates  peritonitis ; 
more,  however,  the  partial  than  the  general  kind.  Where  the 
inflammation  of  the  muscle  is  not  extended,  the  resemblance  to 
inflammatory  affections  of  the  organs  lying  underneath  the  point 
of  tenderness  is  even  greater  than  to  inflammation  of  the  perito- 
neum. Hepatitis,  splenitis,  and  gastritis  have  been  mistaken  for 
the  affection  of  the  abdominal  parietes.  These  errors  can  only  be 
avoided  by  taking  into  account  the  absence  of  disturbed  function 
of  the  suspected  viscus;  often,  too,  the  peculiar  swelling  furnishes 
a  clue  to  the  real  nature  of  the  case.  But  as  regards  the  signs  of 
absence  of  disturbed  function,  we  must  bear  in  mind  that  these 
are  produced  occasionally  in  adjoining  viscera  by  mere  sympathy. 


*  A  case  of  this  kind,  occurring  after  delivery,  is  given  by  Lever,  Guy's 
Hospital  Eeports,  2d  Series,  vol.  viii.  p.  41. 


508  MEDICAL   DIAGNOSIS. 

Thus,  we  have  jaundice  in  abscesses  seated  in  the  walls  in  the 
right  hypochondrium.* 

Can  we  distinguish,  with  anything  like  certainty,  between  ab- 
scesses in  the  abdominal  walls  and  instances  of  partial  peritonitis 
leading  to  collections  of  pus  in  the  peritoneal  cavity  f  I  believe 
not :  for  in  both  there  is  a  tumefaction ;  in  both  the  general 
symptoms  are  much  the  same;  and,  as  happens  sometimes  in 
peritoneal  abscesses,  the  pus  presses  its  way  through  the  parietes 
of  the  abdomen.  How,  then,  are  we  to  know  where  was  the  seat 
of  its  formation  ?  Whenever  we  find  a  swelling  which  has  come 
on  gradually,  or  has  followed  a  blow  or  a  kick  on  the  abdomen, 
or  a  swelling  which  is  very  hard  before  fluctuation  appears; 
whenever  the  softening  of  the  tumor  is  immediately  preceded  by 
distinct  chills,  and  the  skin  covering  it  is  tense,  and  heated,  or 
reddish ;  whenever  there  is  nothing  pointing  to  the  occurrence 
of  partial  peritonitis,  as  an  attendant  on  visceral  disease,  or  as  a 
consequence  of  an  attack  of  general  peritonitis,  we  may  infer, 
from  the  history  and  the  signs,  that  the  aifection  lies  in  the  ab- 
dominal walls.  But  the  skin  is  not  always  discolored  or  hot; 
the  beginning  of  the  swelling  is  sometimes  veiled  in  obscurity, 
and  an  error  in  diagnosis  is  not  discreditable,  because  it  is  un- 
avoidable. In  some  instances  I  have  seen,  in  which  there  was 
great  doubt,  the  aspirator  drew  off  a  very  offensive  pus  and 
broken-down  material ;  and  I  looked  upon  this — as  the  sequence 
proved,  correctly — as  indicating  abscess  in  the  abdominal  walls. 

But  it  is  not  every  case  of  abscess  in  the  walls  which  is  attended 
with  symptoms  that  render  it  likely  to  be  mistaken  for  inflam- 
mation, or  the  results  of  inflammation.  Sometimes  the  preceding 
tumefaction  is  so  hard,  or  it  is  so  long  before  the  process  of  sup- 
puration sets  in,  that  the  affection  is  much  more  liable  to  be  con- 
founded with  abdominal  tumors.  The  most  trustworthy  points 
of  difference  are  furnished  by  a  study  of  the  history  of  the  case, 
and  of  the  mode  of  invasion  ;  by  the  slow  growth  of  the  tumor  on 
the  one  hand,  its  far  more  rapid  growth  on  the  other;  and  by 
the  absence,  or  at  all  events  the  comparative  absence,  of  signs 
denoting;  serious  disturbance  in  one  or  several  of  the  abdominal 
viscera.     Then,  in  doubtful  cases,  the  aspirator  or  the  exploring 

*  As  mentioned  by  Habershon,  Diseases  of  the  Abdomen,  1878. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        509 

needle  will  be  of  use.  The  fluid  thus  obtained  shows,  under  the 
microscope,  shreds  of  broken-down  muscle  and  of  areolar  tissue, 
mixed,  if  suppuration  have  commenced,  with  pus.  Again,  stress 
may  be  laid  on  the  occurrence  of  chills  preceding  the  softening  of 
the  mass.  In  some  patients  the  inflammation  is  unaccompanied 
b/  any  appreciable  signs;  it  leads  to  gradual  changes  in  the  mus- 
cular fibres,  which  do  not  reveal  themselves  until  the  disorganized 
muscle  gives  way.  The  fibres  undergo  softening  or  a  true  fatty 
metamorphosis,  and  the  slightest  force  suffices  to  producer  rupture. 
Not  a  few  cases  have  been  reported  in  which  one  of  the  recti  mus- 
cles has  been  torn  asunder  during  a  fit  of  coughing.  The  seat  of 
laceration  is  generally  about  midway  between  the  umbilicus  and 
the  pubes,  a  little  to  one  side  of  the  median  line ;  the  rent  fills 
with  blood,  occasioning  a  circumscribed  swelling  and  rigidity  of 
the  abdomen.  There  is  sometimes  pain,  with  nausea,  vomiting, 
and  obstinate  constipation.  Nay,  the  symptoms  have  mimicked 
so  closely  a  strangulated  ventral  hernia  as  to  have  led  to  the  per- 
formance of  an  operation.* 

Rheumatism  of  the  Abdominal  Walls.— Occasionally  rheumatism 
attacks  the  abdominal  muscles,  and  gives  rise  to  local  symptoms 
similar  to  those  of  peritonitis.  But  the  pain  is  not  so  constant, 
nor  is  it  spontaneous,  as  in  this  disorder.  It  is  also  less  affected 
by  movements  or  by  pressure.  Not  that  these  diminish  it ;  on 
the  contrary,  they  aggravate  it.  But  deep  pressure  causes  little 
or  no  more  pain  than  slight  pressure;  and  it  is  only  during  certain 
motions — when  the  muscles  are  placed  on  the  stretch — that  the 
pain  is  severe,  or  sometimes,  indeed,  at  all  produced. 

The  pain  is  often  one-sided,  or,  at  any  rate,  much  more  marked 
on  one  side,  and  we  find  no  meteorism,  and  but  slight  fever,  and 
not  the  anxious  expression  of  countenance  of  peritonitis.  More- 
over, the  attack  is  apt  to  happen  in  those  of  rheumatic  tendencies, 
and  there  is  concentrated,  highly  acid,  scalding  urine.  So  strong 
a  degree  of  similarity  may,  however,  exist  between  the  two  diseases 

*  Kichardson's  case,  American  Journal  of  the  Medical  Sciences,  Jan.  1857. 
Further  instances  of  this  accident  are  given  hy  Yirchow,  in  the  "  Wiirzburg. 
Verhandl.,"  Band  vii.  The  description  of  ahscesses  in  the  ahdorninal  parietes 
I  have  drawn  from  cases  coming  under  my  own  notice,  from  manuscript  notes 
taken  hy  Dr.  J.  K.  Kane  at  the  Philadelphia  Hospital,  and  from  the  cases 
collected  in  the  Dictionnaire  des  Dictionnaires  de  iledecine,  art.  "Abdomen." 


510  MEDICAL   DIAGNOSIS. 

as  to  keep  judgment  in  suspense.  In  such  cases  it  is  better  tc 
treat  the  disorder  as  if  it  were  inflammation  of  the  peritoneum. 
In  point  of  fact,  it  may  happen  that  such  inflammation  does  suc- 
ceed to  the  rheumatic  affection  of  the  abdominal  muscles,  and  this 
occurs  chiefly  when  the  disturbance  in  the  muscles  forms  part  of 
an  attack  of  acute  rheumatism  having  a  decided  tendency  to  shift 
its  seat. 

Abdominal  Hysteria. — Xo  disease  simulates  peritonitis  so  closely 
as  hysteria.  The  abdomen  may  be  extremely  painful  to  the  touch, 
swollen  and  distended  with  gas,  fever  may  set  in  temporarily,  and 
yet  the  whole  disorder  be  purely  hysterical.     To  illustrate : 

An  unmarried  woman,  twenty  years  of  age,  placed  herself 
under  my  care,  on  account  of  extreme  tenderness  of  the  abdomen 
and  febrile  irritation,  both  of  which  had  become  developed  in  a 
few  days.  The  abdomen  was  swollen  and  tympanitic,  and  so  sen- 
sitive that  it  would  not  bear  the  pressure  of  her  clothes ;  the  pulse 
was  frequent ;  the  skin  dry  and  warm ;  the  tongue  was  slightly 
coated ;  the  bowels  constipated ;  the  countenance  expressive  of 
distress.  Here  was  certainly  a  group  of  symptoms  like  those  of 
acute  peritonitis.  But  the  absence  of  the  wiry  pulse,  the  compar- 
atively slight  fever, — slighter,  certainly,  than  was  to  be  expected 
from  such  general  and  great  tenderness, — and  the  expression  of 
countenance,  which  was  not  that  of  acute  inflammation  of  the 
peritoneum,  arrested  my  attention.  I  inquired  more  closely  into 
the  case,  and  found  that  the  patient  had  had  similar  attacks  pre- 
viously ;  that  they  had  come  on  sometimes  shortly  before,  some- 
times shortly  after,  her  menstrual  period;  but  that  for  several 
months  her  menses  had  ceased  to  flow.  The  abdominal  tenderness 
M'as  in  reality,  as  she  represented  it  to  be,  very  great;  yet  strong 
pressure  produced  no  more  pain  than  the  lightest  touch.  Nor 
was  the  pain  increased  by  deep  inspiration,  or  by  coughing,  or 
by  extending  the  thighs.  Taking  all  these  circumstances  into 
account,  as  well  as  her  age  and  sex,  her  nervous  temperament, 
instead  of  treating  her  for  acute  peritonitis,  cold  water  injections, 
mild  purgatives,  and  a  mixture  of  assafetida  and  valerian  were 
employed.  Under  these  remedies,  all  the  symptoms  of  the  ap- 
parent peritonitis  speedily  vanished. 

Yet  all  cases  of  abdominal  hysteria  do  not  pass  off  so  quickly ; 
sometimes  they  are  much  more  persistent.     Then,  however,  they 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        511 

are  from  the  onset  unattended  with  fever,  or,  as  the  thermometer 
shows,  the  fever  soon  ceases.  The  absence  of  febrile  excitement, 
too,  especially  if  taken  in  connection  with  the  several  localized  and 
more  or  less  distinctly  circumscribed  spots  of  tenderness,  enables 
us  to  distinguish  between  peritonitis  and  those  instances  of  neural- 
gia of  nerves  supplying  the  abdominal  parietes,  to  which  women 
who  are  laboring  under  disorders  of  the  uterus  are  so  liable.  It 
is  in  these  cases,  as  well  as  in  all  instances  of  abdominal  hysteria, 
that  the  thermometer  proves  a  most  useful  aid  in  the  diagnosis. 

Colic. — As  already  stated,  the  pain  of  colic  is  paroxysmal,  and 
not  attended  with  fever,  or  with  much,  if  any,  tenderness;  while 
it  is  hardly  necessary  to  repeat  that  the  pain  of  an  inflamed  peri- 
toneum is  constant,  and  associated  with  the  greatest  tenderness 
and  with  fever.  Cases  of  colic  do  indeed  occur  in  which  we  find 
fever  and  some  tenderness ;  but  these  signs  then  are  out  of  pro- 
portion to  the  amount  of  pain.  The  pulse  is  not  wiry,  nor  the 
tenderness  so  exquisite  or  so  diffused.  Further,  it  is  not  at  all 
unlikely  that  in  such  cases  the  peritoneum  is  really  in  parts  in- 
jected or  slightly  inflamed.  We  know  that  even  a  more  severe 
form  of  peritonitis  may  follow  colic ;  why  should  not  an  injection 
of  the  membrane  frequently  coexist  ? 

The  same  remarks  are  applicable  to  those  severe  paroxysmal 
pains  which  accompany  the  passage  of  gall-stones  or  of  urinary 
concretions,  or  which  occur  at  the  menstrual  periods.  They  are 
frequently  spoken  of  as  varieties  of  colic,  and,  as  far  as  their 
discrimination  from  peritonitis  goes,  there  is  no  difference, — it  rests 
on  the  same  grounds  precisely ;  for  when  there  is  fever  or  tender- 
ness on  pressure,  it  is  likely  that  inflammation  has  been  set  up  in 
those  parts  in  which,  or  in  the  neighborhood  of  which,  the  pain  is 
felt.  In  the  so-called  uterine  colic,  an  injection  of  the  peritoneum 
has  positively  been  demonstrated. 

Chronic  Peritonitis. — An  acute  attack  of  peritonitis  may 
imperceptibly  assume  a  chronic  form.  The  fever  gradually  dis- 
appears, or  at  all  events  lessens ;  but  the  exudations  into  the  peri- 
toneal cavity,  whether  organized  or  not,  remain,  and  so  do  some 
abdominal  pain  and  tenderness.  In  this  condition  the  patient 
may  continue  for  many  months ;  now  and  then  a  fresh  inflamma- 
tion starting  up  in  the  peritoneum  and  giving  rise  to  acute  symp- 
toms, or  an  intercurrent  severe  diarrhoea  leading  to  rapid  loss  of 


512  MEDICAL    DIAGNOSIS. 

strength.  Again,  the  disease  may  develop  slowly,  be  latent  from 
the  onset,  and  may  not  attract  attention  until  the  abdomen  swells. 
In  all  cases,  no  matter  what  their  origin,  if  they  last  for  any 
length  of  time,  debility  and  emaciation  become  marked  symptoms; 
then  hectic  fever  is  observed;  decided  effusion  into  the  peritoneum 
is  generally  noticed;  the  legs  become  cedematous;  and  the  patient 
may  die  worn  out  and  presenting  the  symptoms  of  pysemic  poison- 
ing. Where  recovery  takes  place,  the  exudation  into  the  peritoneal 
cavity  is  either  discharged  through  adjacent  viscera ;  or  it  may  be 
gradually  reabsorbed;  or  it  may  be  transformed,  more  or  less 
quickly,  into  tissue.  When  the  disease  terminates  in  this  way,  it 
is  apt  to  leave  its  traces  in  a  chronic  thickening  and  roughening  of 
the  peritoneum. 

Chronic  peritonitis  is  most  likely  to  be  confounded  with  affec- 
tions of  the  liver  which  are  attended  by  impediment  in  the  portal 
circle;  and  what  adds  to  the  difficulty  in  diagnosis  is,  that  the 
liver  is  apt  to  atrophy  in  chronic  diffuse  peritoneal  inflammation. 
The  most  trustworthy  signs  of  distinction  are  that,  in  the  latter 
affection,  tenderness  exists,  and  is  under  any  circumstances  much 
greater  and  more  diffuse;  that  there  are  evening  exacerbations 
of  temperature,  a  quickened  pulse,  dark  stools;  and  that,  if  the 
veins  of  the  abdomen  are  dilated,  their  dilatation  is  slight  and 
uniform. 

Chronic  peritonitis  more  usually  comes  on  and  ends  in  a  par- 
ticular fashion.  It  is  insidious  in  its  approach,  and  its  fatal  ter- 
mination is  preceded  by  evident  signs  of  tubercular  or  cancerous 
deposits  in  the  abdominal  cavity  or  in  the  lungs.  The  disease  is 
not  then  simply  chronic  peritonitis,  but  chronic  peritonitis  in  con- 
nection with  a  cachexia.  Cases  of  the  kind  are  commonly  of  long 
duration.  They  are  attended  with  ascites,  and  often  with  very 
considerable  abdominal  distention.  I  shall,  therefore,  postpone 
most  of  what  I  have  to  say  about  their  diagnosis  until  I  come  to 
abdominal  enlargements,  and  shall  then  consider  what  differences 
there  are  between  these  various  forms  of  chronic  peritoneal  affec- 
tions and  other  disorders  leading  to  ascites  and  to  consequent 
abdominal  distention. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        513 

Diseases  attended  with  Pain  and  Tenderness  in  the  Eight 

Iliac  Fossa. 

Affections  of  the  Caecum  and  its  Appendix. — Standing 
clinically  in  close  connection  with  inflammatory  affections  of  the 
peritoneum,  are  the  disorders  of  the  caecum  and  its  appendix. 
They  frequently  give  rise  to  a  partial  peritoneal  inflammation  ; 
they  sometimes  lead  to  fatal  general  peritonitis.  Their  chief 
manifestations  are  localized  pain  and  tenderness,  and  a  tumefac- 
tion in  the  right  iliac  fossa.  In  truth,  they  are  the  disorders  which 
pre-eminently  occasion  signs  of  disturbance  in  this  region. 

Inflammation  is  the  most  common  of  the  morbid  processes 
affecting  the  csecum  and  its  appendix.  This  inflammation  may  be 
limited  to  the  csecum ;  it  may  have  its  seat  entirely  in  the  appen- 
dix. It  may  be  equally  violent  in  both ;  it  may  cause  ulceration 
in  one  and  not  in  the  other.  It  may  originate  in  the  loose  areolar 
tissue  around  the  csecum  ;  it  may  begin  in  the  csecum  and  spread 
from  its  peritoneal  covering  to  the  areolar  tissue  of  the  iliac  fossa. 
Here  are  certainly  conditions  which  are  different,  and  between 
which  it  would  be  very  desirable  to  be  able  to  discriminate.  But 
such  discrimination  is,  for  the  most  part,  impossible.  If  an  in- 
flammatory affection  of  this  out-of-the-way  corner  of  the  ali- 
mentary tube  have  been  detected,  we  cannot,  with  any  certainty, 
go  further.  The  history  and  progress  of  the  disease  may  determine 
the  exact  diagnosis;  but  we  cannot  always  rely  upon  their  aid. 

Inflammation  of  the  csecum  or  of  its  appendix  is,  in  the  ma- 
jority of  instances,  caused  by  accumulation  of  hardened  faeces,  or 
by  hardened  bodies  which  have  there  become  impacted.  Both 
structures  are  also  at  times  found  highly  inflamed  in  cases  of 
dysentery.  But  here  the  inflammation  forms  part  of  a  more  gen- 
eral inflammation  of  the  bowel ;  and  as  it  is  not  my  present  object 
to  consider  the  disorders  in  which  the  csecum  may  participate, 
but  rather  those  in  which  it  is  chiefly  concerned  and  without  any 
other  part  of  the  tube  being  implicated,  such  accidental  inflamma- 
tion need  not  be  further  alluded  to. 

Now,  the  morbid  phenomena  which  attend  inflammation  of  the 
csecum  or  its  appendix  will  vary  materially  according  to  the  acute- 
ness  of  the  disorder,  its  course,  its  termination  in  ulceration,  the 
presence  or  absence  of  peritonitis,  and  the  extent  and  rapidity  of 

33 


514  MEDICAL   DIAGNOSIS. 

appearance  of  this  dangerous  complication.  Sometimes  the  cseoal 
disease  sets  in  suddenly  with  all  the  symptoms  and  signs  of  a 
severe  local  peritonitis  in  the  right  iliac  fossa.  There  is  pain, 
with  tenderness,  a  chill,  and  fever;  and  the  pain  and  tenderness 
soon  spread,  as  the  peritoneal  inflammation  becomes  more  general. 
But  usually  the  complaint  is  of  more  gradual  formation,  and 
presents  the  following  history  and  symptoms.  The  patient  has 
been  suffering  for  some  time  from  constipation,  or  alternately  from 
diarrhcea  and  constipation.  He  has  a  dull  pain  referred  prin- 
cipally to  the  iliac  fossa,  and  sometimes  radiating  to  the  hips. 
When  the  iliac  region  is  examined,  it  is  tender  to  the  touch,  full 
and  hard,  and  sounds  dull  on  percussion,  while  around  the  dulness 
there  is  a  very  tympanitic  sound,  if  the  intestine,  as  it  often  is,  be 
much  distended  with  gas.  Colicky  pains  occur  from  time  to  time, 
but  are  mainly  confined  to  the  lower  portion  of  the  abdomen.  In 
such  cases  there  has  been,  in  all  likelihood,  a  distention  of  the 
caecum,  which  favors  an  accumulation  of  faeces,  and  these  again 
have  acted  as  exciting  causes  to  an  inflammation ;  or  foreign 
bodies,  such  as  cherry-stones  or  concretions  of  various  kinds,  have 
become  impacted  in  the  caecum  or  the  vermiform  appendix,  and 
have  gradually  provoked  the  morbid  action. 

In  its  further  progress  the  case  exhibits  varied  features:  it  may 
end  in  resolution ;  or  the  tenderness  in  the  iliac  fossa  may  become 
greater,  and  vomiting,  fever,  and  the  marked  signs  of  a  local 
peritonitis  appear ;  or  ulceration  of  the  bowel,  and  more  frequently 
still  of  the  appendix,  may  allow  a  discharge  of  extraneous  matter 
into  the  peritoneal  cavity,  which  produces  violent  general  peri- 
tonitis ;  or,  again,  the  bowel  may  become  so  paralyzed  that  it  can 
no  longer  contract  or  propel  its  contents,  and  the  patient  dies  with 
all  the  distressing  signs  of  intestinal  obstruction.  In  more  fortu- 
nate instances  the  constipation  at  length  yields  to  remedies;  large 
quantities  of  hardened  faecal  matter  are  passed;  and  the  distended 
and  irritated  intestine  gradually  regains  its  tone. 

Other  affections  than  those  of  the  bowels  may  give  rise  to 
phenomena  supposed  to  indicate  typhlitis.  It  does  not  at  first 
sight  seem  likely  that  this  would  be  the  case  with  pneumonia. 
Yet  the  mistake  has  been  committed.  Pain  is  sometimes  referred 
to  the  right  groin  in  pneumonia,  and  there  is  soreness  there,  con- 
nected probably  with  the  efforts  at  coughing  and  the  disordered 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         515 

breathing.  Nay,  I  have  known  poultices  applied  to  the  right  iliac 
fossa  to  relieve  the  inflammation  which  really  was  in  the  chest. 
An  examination  of  this  part  of  the  body  will  of  course  at  once 
explain  the  true  character  of  the  symptoms. 

Inflammation  of  the  loose  areolar  tissue  around  the  csecum 
presents  much  the  same  symptoms  and  signs  as  typhlitis.  This 
perityphlitis  is,  in  truth,  frequently  combined  with  inflammation 
of  the  caecum  or  its  appendix.  Even  where  perforation  has  taken 
place,  the  matters  may  be  detained  in  the  neighborhood  of  the 
lesion,  giving  rise  to  circumscribed  inflammation  around  the 
cascum,  and  to  an  abscess.  Subsequently,  the  collection  of  pus 
may  find  its  way  into  neighboring  viscera,  or  be  discharged  exter- 
nally, when  the  ruptured  intestine  may  heal ;  although  sometimes 
the  perforation  remains  open,  and  fsecal  matter  is  found  oozing 
through  the  abdominal  parietes.  The  tumefaction  which  the 
abscess  occasions,  whether  it  be  or  be  not  connected  with  disease 
of  the  intestine,  is  generally  very  evident.  When,  however,  the 
pus  burrows  under  the  iliac  fascia,  the  swelling  may  be  slight. 
But  under  such  circumstances  there  appears  a  characteristic  sign  : 
the  pain,  on  moving  the  right  foot,  is  intense,  because  the  iliac 
muscles  become  involved  in  the  disorder.  If  the  swelling  be 
great,  there  may  be  oedema  of  the  foot  and  numbness  of  the  thigh, 
from  pressure  on  the  vein  and  nerves. 

When  these  abscesses  in  the  right  iliac  fossa  are  not  combined 
with  disease  of  the  adjoining  bowel,  they  give  rise  to  but  slight 
fever  and  pain ;  the  action  of  the  intestine  is  not  materially 
interfered  with  ;  there  is  no  nausea ;  and,  as  the  abscesses  fre- 
quently have  a  favorable  termination  by  discharging  into  the 
intestine,  or  through  the  abdominal  parietes,  we  do  not  observe 
acute  peritonitis  supervening  on  them,  as  it  does  so  often  on 
ulcerative  disease  of  the  intestine  or  its  appendix.  Yet  there  are 
cases  in  which  judgment  is  held  in  suspense;  in  which  it  cannot 
be  said  whether  the  swelling  does  or  does  not  communicate  with 
the  bowel.  Fortunately,  this  makes  little  difference  in  respect  to 
treatment. 

Independently  of  the  difficulty  of  distinguishing  between  the 
inflammatory  disorders  of  this  portion  of  the  alimentary  tube  and 
its  surroundings,  there  are  sources  of  perplexity  introduced  by  the 
circumstance  that  other  diseases  of  the  caecum  and  affections  of 


516  MEDICAL    DIAGNOSIS. 

adjacent  structures  may  simulate  typhlitis  and  perityphlitis. 
Thus,  distention  and  cancer  of  the  caecum ;  inflammation  and 
ulceration  of  the  ileum ;  suppuration  of  the  kidney  or  its  en- 
velopes ;  psoas  abscess ;  abscesses  of  the  abdominal  walls ;  intus- 
susception of  the  intestine;  and  inflammation  of  the  ovary, — 
occasion  some  of  them  pain  and  tenderness  in  the  right  iliac  fossa, 
some  of  them  a  fulness  in  this  region :  therefore  all  of  them  have 
signs  which  they  share  with  an  inflammation  of  the  caecum.  But, 
although  they  all  offer  points  of  similitude,  they  also  offer  points 
of  contrast. 

A  distention  of  the  ccecum  gives  rise  to  fulness  in  the  right  iliac 
fossa,  and  to  pain,  but,  unless  associated  with  inflammation,  not 
to  tenderness  or  to  fever ;  copious  enemata  too,  or  purgatives, 
clear  out  the  faeces  which  accumulate  from  want  of  power  of  the 
bowel  to  propel  them,  and  the  dulness  on  percussion  vanishes 
after  the  free  evacuations.  Another  element  of  distinction  is 
furnished  by  the  circumstance  that  those  who  suffer  from  atony 
of  this  portion  of  the  alimentary  tube  labor  under  it  for  a  long 
time;  they  are  generally  highly  nervous  persons,  of  sallow  com- 
plexion and  with  impaired  digestion,  whose  bowels  are  habitually 
constipated,  and  who  complain  of  attacks  of  spasmodic  pain  and 
fulness  in  the  iliac  region.  Yet,  although  there  is  fulness,  there 
is  no  dulness  on  percussion,  and  no  hard  swelling  is  detected, 
unless  the  caecum  be  loaded  with  faeces.  On  the  contrary,  the 
caecum  and  ascending  colon  generally  show,  by  the  excessive  tym- 
panitic resonance  when  they  are  percussed,  that  they  are  distended 
with  flatus. 

In  that  rare  disease,  cancer  of  the  ccecum,  there  is  a  fixed,  firm 
swelling;  but  it  is  of  very  gradual  growth,  and  the  disorder 
generally  produces  a  stricture  of  the  bowel,  and  is  associated  with 
malignant  disease  in  other  parts  of  the  body.  Ulceration  of  the 
ileum  produces  pain  and  tenderness  in  the  iliac  fossa.  But,  com- 
bined as  it  generally  is  with  phthisis  or  with  typhoid  fever,  the 
history  of  the  case  gives  a  clue  to  the  probable  nature  of  the 
malady.  Moreover,  there  is  not  present  a  tumefaction  which 
sounds  dull  on  percussion.  Should,  however,  perforation  of  the 
bowel  take  place  before  the  patient  is  seen,  and  general  peritonitis 
come  on,  the  diagnosis  is  not  so  readily  made,  because  we  are 
deprived  of  the  decisive  proof  furnished  by  the  hard  swelling. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         517 

As  regards  tumors  of  the  kidney  and  abscesses  in  it  or  connected 
with  its  envelopes,  the  situation  of  the  swelling  is  not  exactly  in 
the  ileo-csecal  region,  or  at  all  events  it  is  not  confined  to  this  spot. 
The  mass  of  the  tumor  lies  in  the  loin,  or  above  the  anterior 
termination  of  the  crest  of  the  ilium;  and  the  urine  contains 
ingredients,  such  as  pus,  or  blood,  or  heavy  deposits  of  urates 
or  phosphates,  which  show  that  the  secretion  of  the  kidney  is 
abnormal. 

An  inflammation  in  or  about  the  right  ovary  gives  rise  to  pain 
and  tenderness  in  the  right  iliac  region,  and  to  fever.  But  it  is 
attended  with  disturbance  of  the  uterine  functions,  and  occasions 
no  very  perceptible  swelling.  A  tumor  of  the  ovary  or  of  the 
uterus  may  produce  a  visible  tumefaction ;  but,  springing  as  it 
does  out  of  the  pelvis,  its  exact  seat,  its  bulk,  its  shape,  the 
absence  of  marked  intestinal  symptoms,  and  a  per  vaginam  ex- 
amination will  permit  its  cause  to  be  discovered. 

An  invagination  of  the  intestine  has  a  different  history,  and 
makes  its  appearance  suddenly  with  such  peculiar  signs  that, 
although  it  may  be  likewise  the  occasion  of  a  tumor  in  the  right 
iliac  region,  it  can  generally  be  distinguished  from  csecal  disease. 
Yet,  where  the  latter  leads  to  intestinal  obstruction,  the  diagnosis 
is  not  always  obvious. 

So,  too,  it  is  with  abscesses  in  or  near  the  region  in  which  those 
connected  with  the  csecurn  occur.  Their  discrimination  is  far  from 
being  invariably  an  easy  matter.  An  abscess  in  the  abdominal  walls 
furnishes  very  many  of  the  signs  of  abscess  around  the  csecum. 
The  most  trustworthy  source  of  distinction  is,  that  the  former 
is  unassociated  with  intestinal  irritation,  while  the  latter,  from 
its  being  often  connected  with  a  disorder  of  the  caecum,  is  not 
uncommonly  so  combined.  Then  the  pus  discharged  is,  for  the 
same  reason,  in  some  cases  very  offensive,  and  of  fsecal  odor. 
Abscesses  in  the  abdominal  walls  are  sometimes  symptomatic  of 
a  more  distant  lesion,  as  of  caries  of  a  rib.* 

Now,  this  character  of  the  pus,  were  it  more  generally  observed, 
would  equally  serve  as  a  most  valuable  differential  mark  between 
the  matter  which  finds  its  way  to  the  surface  from  a  caecal  and 
from  a  psoas  abscess.     But,  as  it  is  not  constant,  we  have  to  apply 

*  Oppolzer,  Wien.  Med.  "Wochensch.,  1862. 


518  MEDICAL    DIAGNOSIS. 

other  tests  to  the  recognition  of  a  psoas  abscess.  A  psoas  abscess 
is  associated  with  caries  of  the  vertebrae :  an  excurvation  of  the 
spine,  dorsal  pain  and  tenderness  testify  to  this  connection.  It 
occurs  in  scrofulous  persons,  and,  although  gradual  in  its  forma- 
tion, is  often  sudden  in  its  manifestation  ;  for  not  unusually  a 
fluctuating,  painless  tumor  appears  below  Poupart's  ligament  as 
the  first  positive  sign  of  this  formidable  affection.  Yet,  preceding 
the  pointing  of  the  abscess  at  this  spot,  there  are  often  indications 
of  irritation  in  those  muscles  in  the  sheath  of  which  the  pus  travels; 
there  is  difficulty  in  extending  the  leg;  an  inability  to  stand  up- 
right; and  a  dull,  uneasy  sensation  in  the  loins,  which  the  patient 
persists  in  regarding  as  rheumatic.  Of  all  these  signs,  there  are 
none  more  important,  as  sources  of  distinction,  than  the  seat  of 
the  visible  abscess  and  its  painless  nature.  The  interference  with 
the  movements  of  the  right  leg  is  not  so  valuable  a  sign  as  it 
appears  at  first  sight  to  be ;  since  when  the  iliac  muscle  is  involved 
the  same  difficulty  in  moving  the  limb  may  exist;  and  the  iliac 
muscle  may  be  implicated  in  an  inflammation  of  the  loose  areolar 
tissue  around  the  caecum  by  the  inflammation  extending  to  the 
iliac  fascia  and  causing  pus  to  collect  under  it :  what  surgeons  term 
iliac  abscesses  are,  indeed,  collections  of  pus  under  this  fascia. 
And,  in  point  of  fact,  they  not  unfrequently  originate  near  the 
caecum,  or  spread  to  the  tissues  surrounding  this  portion  of  the 
bowel,  break  into  the  cavity  of  the  peritoneum,  and  therefore 
practically  constitute  perityphlitic  abscesses.* 

Disorders  attended  with  Constipation,  and  of  which  it  is  a 
Prominent  Symptom. 

An  inactive  state  of  the  bowels  is  often  but  a  concomitant  of 
some  disorder  which  presents  phenomena  much  more  striking  than 
the  imperfect  voidance  or  the  prolonged  retention  of  the  faeces. 

*  See,  for  collection  of  cases,  and  for  observations  on  these  abscesses  and 
on  diseases  of  the  caecum,  J.  Burne,  Medico-Chirurg.  Transact  ,  vol.  xx.  ; 
Copland,  Dictionary  of  Practical  Medicine,  article  "Caecum;"  Dunglison, 
Practice  of  Medicine  ;  Jackson,  Letters  to  a  Young  Physician  ;  Oppolzer  on 
"Perityphlitis,"  Allg.  Wien.  Med.  Zeit.,  Nos.  20  and  21,  1858;  Bartholow, 
Aroer.  Journ.  of  Med.  Sci.,  Oct.  1866,  Gouley,  New  York  Medical  Kecord, 
Feb.  1875;  Gurdon  Buck,  ib.,  1876;  and  Transactions  of  New  York  Acad- 
emy of  Medicine,  1876  ;  Habershon,  Diseases  of  the  Abdomen,  London,  1878. 


DISEASES    OF    THE    INTESTINES    AXD    PERITONEUM.         519 

But  there  are  cases  in  which  the  constipation  is  a  very  prominent 
symptom,  in  which  it  constitutes  the  ailment  for  which  we  are 
consulted,  and  in  which  it  furnishes  by  far  the  most  decisive 
proof  of  a  serious  morbid  condition  of  the  intestine.  Now,  these 
cases  are  either  those  in  which  the  constipation  arises  suddenly, 
or  at  any  rate  becomes  suddenly  aggravated,  is  attended  with 
severe  symptoms,  and  is  often  insuperable;  or  those  in  which  it  is  a 
habitual  state  and  not  associated  with  any  signs  of  urgent  distress. 

I  shall  describe  the  former  set  of  cases  first,  because  they  bear 
a  close  relation  to  affections  we  have  just  been  considering, — to 
acute  enteritis  and  peritonitis.  Not  that  I  mean  here  to  dwell 
upon  the  constipation  which  occurs  in  these  maladies, — it  forms 
only  one  of  the  symptoms,  and  that  not  the  most  distinctive, — 
but  I  wish  to  discuss  the  constipation,  frequently  insurmountable, 
produced  by  an  obstruction  to  the  passage  of  the  intestinal  con- 
tents, and  which  often  brings  with  it  acute  inflammation  of  the 
bowel  and  of  its  serous  investment. 

Intestinal  Obstruction. — Intestinal  obstruction,  when  com- 
ing on  suddenly,  manifests  itself  generally  in  the  following  man- 
ner. A  person,  previously  in  good  health,  or  perhaps  of  costive 
habit,  notices  that  his  bowels  have  not  been  moved  for  several 
days,  and  that  he  has  an  uneasy  feeling  in  the  abdomen  in  conse- 
quence. He  takes  the  purgative  he  is  wont  to  employ,  but  with- 
out the  usual  effect.  Something  more  active  is  tried,  and  still 
the  bowels  remain  obstinately  bound.  Colicky  pains  have  in  the 
mean  time  made  their  appearance,  or,  if  present  from  the  onset 
of  the  disorder,  have  become  aggravated.  He  becomes  alarmed, 
and  sends  for  his  physician.  On  his  arrival,  the  medical  attendant 
sees  that  there  is  indeed  cause  for  alarm.  He  finds  the  abdomen 
somewhat  distended,  but  not  painful,  or  perhaps  only  slightly 
painful,  on  pressure.  But  through  its  parietes  may  be  noticed  the 
violent,  rolling  motion  of  the  excited  intestine.  Vomiting  sets  in, 
— first,  of  the  substances  contained  in  the  stomach  or  of  a  bilious 
fluid,  and,  as  the  case  progresses,  of  stercoraceous  matter.  In  this 
way,  unless  nature  or  art  come  to  the  rescue,  the  disease  con- 
tinues; and  signs  of  inflammation  of  the  bowels,  and  with  them 
fever,  appear  as  preludes  to  the  fatal  termination.  Sometimes, 
however,  the  patient  becomes  gradually  exhausted ;  there  are  no 
tenderness  and  fever,  but  a  cool  skin,  a  quick,  small  pulse,  a  coun- 


520  MEDICAL    DIAGNOSIS. 

tenance  ghastly  and  panic-stricken.  Severe  paroxysms  of  pain, 
alternating  with  intervals  of  ease,  may  occur  to  the  last  moment. 
But,  in  spite  of  the  utter  prostration,  the  mind  generally  retains 
its  clearness  until  death  comes  to  put  a  merciful  end  to  the  pro- 
longed and  irremediable  suffering.  Should  recovery  take  place, 
large  quantities  of  fsecal  matter  are  discharged,  and  all  the  symp- 
toms of  the  impediment  speedily  disappear. 

Such  are  the  phenomena  presented  by  an  intestinal  obstruction. 
They  are  too  striking  to  permit  of  errors  in  diagnosis.  Yet  errors 
have  been  committed,  and  are  still  of  frequent  occurrence,  because 
the  history  of  the  attack  and  the  sequence  of  the  symptoms  are 
not  taken  into  account.  Many  a  person  laboring  under  enteritis 
or  peritonitis  has  been  violently  purged  to  remove  the  stubborn 
constipation  believed  to  be  due  to  a  mechanical  hinderance  in  the 
bowels;  and,  on  the  other  hand,  many  a  case  of  intestinal  obstruc- 
tion has  been  treated  solely  with  reference  to  the  inflammation 
which  may  attend  it,  and  without  regard  to  the  source  of  this  in- 
flammation. Yet  it  is  not  ordinarily  difficult  to  distinguish  which 
is  cause  and  which  effect.  A  case  that  begins  with  colicky  pains 
and  obstinate  constipation,  in  which  at  first,  in  spite  of  the  pain, 
there  is  little  or  no  tenderness  or  fever;  in  which  the  thermometer 
does  not  indicate  materially  raised  temperature;  in  which  vomit- 
ing soon  occurs;  in  which  fulness  on  palpation  and  dulness  on 
percussion  may  on  careful  examination  be  detected  at  or  above 
the  point  of  stoppage;  and  in  which  fsecal  matter  is  ejected  by  the 
mouth  after  a  stoppage  of  the  bowels  of  a  few  days'  duration, — 
is  not  primarily,  whatever  may  be  the  ultimate  complications, 
enteritis  or  peritonitis.  A  case  presenting  almost  from  the  onset 
fever  and  great  tenderness;  in  which  vomiting  of  fascal  matter,  if 
it  happen  at  all,  does  not  happen  until  late;  in  which  diarrhoea 
is  sometimes  found  to  supersede  the  enduring  constipation, — is 
inflammation  of  the  intestine  or  of  the  peritoneum,  but  not  a 
mechanical  obstruction. 

Only  in  very  rare  instances,  and  especially  when  the  bowel  is 
invaginated,  is  this  formidable  malady  so  quickly  succeeded  by 
inflammation  as  seemingly  to  make  its  appearance  with  the  signs 
of  peritonitis.  Should  the  disease  then  run  a  rapid  course,  and 
stercoraceous  vomiting  not  occur,  an  error  in  diagnosis  is  unavoid- 
able.    Should  it  be,  however,  of  some  duration,  the  unyielding 


DISEASES    OP    THE    INTESTINES    AND    PEEITONEUM.  521 

constipation  and  the  character  of  the  vomit  come  to  our  aid,  and, 
casting  the  signs  of  inflammation  more  and  more  into  the  back- 
ground, force  the  conviction  on  the  mind  that  they  are  dependent 
on  an  impassable  barrier  to  the  intestinal  contents. 

The  symptoms  upon  which  I  have  been  dwelling  as  pointing 
toward  an  intestinal  obstruction  bear  a  close  resemblance  to  those 
of  external  strangulated  hernia.  In  truth,  they  not  only  resemble 
but  are  identical  with  those  of  this  affection.  Hence,  in  every 
case  of  obstinate  constipation,  each  point  which  may  be  the  seat 
of  a  hernia  must  be  explored  by  the  eye  and  the  hand.  No  mo- 
tives of  false  delicacy,  no  reluctance  on  the  part  of  the  patient, 
should  prevent  the  practitioner  from  insisting  on  a  search,  the 
neglect  of  which  may  cost  a  life. 

It  would  be  foreign  to  the  object  of  this  work  were  I  to  attempt 
to  discuss  the  external  signs  by  which  a  strangulation  of  the  intes- 
tine at  a  hernial  opening  manifests  itself.  This  belongs  to  sur- 
gical, not  to  medical,  diagnosis.  Nor  shall  I,  for  the  same  reasons, 
do  more  than  indicate  that  it  is  at  the  groin,  at  the  umbilicus,  at 
the  side  of  the  anus,  or  through  the  ischiatic  notch  that  the  gut 
descends  and  forms  a  tumor,  and  that  these  are,  therefore,  the 
regions  to  be  scrutinized. 

But  there  is  one  part  of  the  subject,  of  importance  alike  to  the 
physician  and  to  the  surgeon,  which  I  cannot  pass  by  without  a 
few  words,  since  it  may  be  a  cause  of  much  perplexity, — namely, 
the  possibility  of  intestinal  obstruction  taking  place  in  a  person 
laboring  under  an  irreducible  hernia  and  simulating  strangulation 
without  any  strangulation  having  occurred.  Of  this  the  following 
case  furnishes  an  example. 

In  October,  1857,  I  was  requested  by  a  physician  to  see  with 
him  a  person,  the  mother  of  thirteen  children,  who  had  been  for 
several  days  laboring  under  obstinate  constipation.  Large  doses 
of  mercurials,  croton  oil,  and  turpentine  enemata  had  failed  to 
procure  a  passage,  and  the  patient  was  becoming  very  much 
frightened  about  herself.  Nor  was  her  situation  one  free  from 
danger.  She  had  considerable  pain  in  the  abdomen  ;  she  had 
been  vomiting  stercoraceous  matter  profusely  ;  the  rolling  of  the 
intestines  could  be  plainly  perceived.  On  her  right  side  was  a 
small  irreducible  femoral  hernia,  which,  on  inquiry,  was  found 
to  have  existed  for  many  years.     It  was  not  painful  on  pressure, 


522  MEDICAL    DIAGNOSIS. 

nor  was  the  skin  covering  it  discolored;  neither  did  the  mass 
itself  communicate  an  impulse  during  the  act  of  coughing.  Now, 
here  were  signs  of  a  serious  impediment  to  the  onward  passage 
of  the  intestinal  contents,  as  the  faecal  vomiting  and  the  rolling 
of  the  intestines  showed  plainly.  But  what  was  its  nature?  Was 
it  due  to  strangulation  at  the  hernial  opening?  Was  it  an  internal 
intestinal  obstruction? 

An  accurate  examination  of  the  abdomen  did  not  throw  much 
light  on  these  questions.  The  belly  was  moderately  tympanitic, 
and  not  painful  to  the  touch,  except  when  the  pressure  was  con- 
siderable. The  rolling  of  the  intestines  was  perhaps  more  obvious 
on  the  left  side;  but  nowhere  could  a  tumor  be  felt.  Taking  all 
the  circumstances  of  the  case  into  account, — the  fact  that  the 
patient  was  of  costive  habit ;  that  she  was  subject  to  attacks  of 
colic  and  of  obstinate  constipation  ;  that  there  was  nothing  to 
prove  that  the  hernia  had  recently  increased,  or  was  in  any  way 
inflamed, — I  was  led  to  the  conclusion  that  the  case  was  not  one 
of  hernial  strangulation,  but  of  internal  intestinal  obstruction ; 
and  she  was  treated  for  this.  Copious  warm  water  injections 
were  thrown  into  the  colon  through  a  flexible  tube;  her  abdomen 
was  rubbed  with  mercurial  ointment.  But  all  in  vain :  she  con- 
tinued vomiting  fsecal  matter. 

Her  situation  now  appeared  desperate.  She  had  not  had  a  pas- 
sage for  six  days — remedies  had  failed  to  procure  her  one ;  she 
was  steadily  sinking.  Knowing  that  sometimes  the  gut  may  be 
strangulated  at  a  hernial  opening  without  much  pain  or  tender- 
ness, the  counsel  of  an  eminent  surgeon  was  sought,  to  aid  in  de- 
termining whether  this  was  not  the  cause  of  the  impediment.  He 
thought  it  probable  that  it  was,  and  proposed  an  operation,  to 
which  consent  was  reluctantly  obtained.  The  patient  was  ether- 
ized, and  the  hernial  section  rapidly  and  skilfully  performed  ;  but 
no  constriction  was  found.  The  wound  was  closed,  and  large 
doses  of  opium  were  administered  to  the  unhappy  sufferer,  so 
as  to  mitigate,  as  far  as  practicable,  the  torturing  distress  of  the 
only  termination  to  the  case  which  seemed  possible.  On  the  day 
after  the  operation,  the  intestines  had  ceased  to  roll ;  there  was 
no  vomiting.  But  stercoraceous  vomiting  reappeared  two  days 
afterward,  and  the  rolling  of  the  intestines  was  occasionally, 
although  faintly,  perceptible. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.         523 

The  patient's  exhaustion  was  now  extreme ;  her  pulse  was  very 
quick  and  small ;  her  skin  cold,  of  a  dirty  look ;  the  odor  of  the 
breath  and  of  the  whole  body  offensive ;  and  the  eyes  sunken  and 
surrounded  by  a  broad  leaden  ring.  There  was  slight  pain  on 
pressure  between  the  umbilicus  and  the  sigmoid  flexure.  The 
vomiting  had  ceased,  or  occurred  only  very  occasionally.  Al- 
though there  was  little  hope,  we  had,  as  soon  as  admissible  after 
the  operation,  recommenced  rubbing  mercurial  ointment  over  the 
abdomen,  and  giving  injections  in  the  manner  before  described. 
This  was  continued  until,  to  our  great  gratification,  one  morning, 
after  a  tube  had  been  passed  a  distance  of  several  feet  into  the 
colon,  the  patient  had  a  copious  discharge  of  tarry  faecal  matter 
from  her  bowels, — seventeen  days  after  the  symptoms  of  complete 
intestinal  obstruction  had  declared  themselves  by  the  occurrence 
of  stercoraceous  vomiting. 

This  case  is  instructive  in  more  than  one  respect.  It  teaches 
that  recovery  may  take  place  most  unexpectedly  after  the  patient 
has  been  kept  at  death's  door  for  many  days.  It  shows  the 
beneficial  results  of  keeping  the  colon  filled  with  fluid  in  instances 
of  intestinal  obstruction;  and,  in  a  diagnostic  point  of  view,  it 
illustrates  a  difficulty  which  any  practitioner  may  have  to  en- 
counter in  attending  a  patient  who  is  the  subject  of  a  long-standing 
hernia. 

Supposing,  however,  that  we  have  sufficient  grounds  for  the 
opinion  that  no  hernia  exists,  and  that  the  symptoms  are  alto- 
gether owing  to  an  obstacle  seated  at  some  portion  of  the  intestine 
within  the  abdomen:  can  we  go  any  further?  can  wre  determine 
the  exact  position  of  the  impediment,  and  what  its  nature  is  ?  We 
know,  from  dissection,  how  varied  are  the  conditions  which  lead 
to  sudden  and  invincible  constipation.  We  know  that  intussus- 
ceptions, twists,  displacements,  strictures  of  the  gut,  bands  and 
adhesions,  or  gaps  in  the  omentum,  foreign  bodies,  impacted  fasces, 
gall-stones,  and  spasmodic  contraction  of  the  intestine,*  may  all 
occasion  intestinal  obstruction,  and  some  of  these  states  even  an 
internal  strangulation.  Can  we  distinguish  these  different  lesions 
from  one  another  at  the  bedside  ?  In  certain  cases  we  can, — we 
can  determine  exactly  both  the  position  and  the  character  of  the 

*  Archives  Generales,  Aua;.  1868. 


524  MEDICAL    DIAGNOSIS. 

lesion ;  in  others  there  is  no  clue  to  an  accurate  discernment  of 
either.* 

Of  the  causes  of  intestinal  obstruction,  intussusception  or  in- 
vagination is  the  most  frequent  and  at  the  same  time  the  most  sus- 
ceptible of  being  recognized  during  life.  Part  of  the  bowel  becomes 
inverted,  slipping  for  a  variable  distance  into  the  cavity  of  the 
adjoining  upper  or  lower  portion.  Inflammation  is  generally  soon 
set  up,  and  produces  infiltration  of  the  tissues  and  their  tumefac- 
tion, and  often  leads  to  adhesions  between  the  opposed  serous  sur- 
faces, and  to  effusions  of  blood  and  mucus  into  the  canal.  The 
swelling  entirely  blocks  up  the  tube;  yet  it  does  not  of  necessity 
do  so.  The  congestion  and  inflammation  which  have  caused  the 
tumefaction  may  spread  rapidly  over  the  serous  membrane,  and 
the  patient  may  die  from  general  peritonitis.  But  sometimes  in 
this  inflammation  that  is  lighted  up  at  the  seat  of  the  ileus  lies 
the  safety  of  the  patient.  It  may  give  rise  to  adhesive  inflam- 
mation of  the  opposed  serous  coats  of  intestine,  and  ultimately  to 
a  sloughing  off  of  the  invaginated  part  and  its  discharge  into  the 
bowel,  while  the  annular  mass  of  adhesive  lymph  surrounding  the 
seat  of  ulceration  maintains  the  continuity  of  the  intestinal  canal, 
and  thus  the  inflammation  may  pave  the  way  to  a  favorable  issue 
by  restoring  the  calibre  of  the  tube, — sufficiently,  at  any  rate,  to 
permit  of  the  transit  of  its  contents. 

Now,  these  pathological  peculiarities  develop  special  symptoms 
which  not  unfrequently  enable  us  to  determine  the  nature  of  the 
obstruction.  When  the  intussusception  takes  place  rapidly,  a  sud- 
den local  pain  is  produced,  recurring  in  paroxysms,  and  likely  to 
be  referred  to  the  seat  of  the  disturbance.  The  pain  is  quickly 
followed  by  vomiting,  by  constipation,  and  by  peritonitis.  But 
the  constipation  is  not  so  absolute  as  in  other  cases  of  intestinal 
impediment.  Sometimes,  in  fact,  owing  to  the  invaginated  bowel 
remaining  open,  the  liquid  contents  of  the  intestine  may  pass 
through  the  intussuscepted  part  and  produce  a  deceptive  diar- 
rhoea; yet  oftener  will  occur  tenesmus,  and  discharges  of  the 
bloody  mucus  and  serum  which  have  accumulated  in  the  intestine. 

*  From  the  method  of  the  introduction  of  the  whole  hand  into  the  rectum 
rmuh  lias  heen  expected.  But  experience  has  not  confirmed  these  expecta- 
tion-. In  three  cases  of  intestinal  obstruction  examined  by  Walsham  (St. 
Bartholomew's  Hospital  Keports,  1870  i  the  hand  in  all  failed  to  detect  a  lesion. 


DISEASES    OF    THE    INTESTINES   AND    PERITONEUM.         525 

Both  of  the  latter  signs  are  eminently  diagnostic  of  the  lesion. 
Still  more  so  would  be  feeling  the  end  of  the  invaginated  gut  by 
an  exploration  of  the  rectum,  or  finding  the  loosened  segment  of 
the  bowel  in  the  stools.  But  of  course  it  is  only  in  a  certain 
class  of  cases,  those  in  which  the  lower  portion  of  the  canal  is 
affected,  or  which  have  been  sufficiently  protracted  to  allow  of  the 
curative  efforts  of  nature  being  accomplished,  that  signs  so  strictly 
pathognomonic  are  met  with. 

The  casting  off  of  the  sloughed  portion  of  the  intestine  is,  we 
are  informed  by  several  observers,  always  attended  with  hemor- 
rhage. Whether  this  be  the  cause  of  the  hemorrhage  or  not,  it 
is  undoubted  that  purging,  nay,  sometimes  vomiting,  of  blood,  is 
among  the  most  important  differential  signs  of  intussusception. 
But  a  sign  more  valuable,  because  so  much  more  common,  is 
the  presence  of  a  tumor.  Its  seat  varies,  of  course,  with  the  seat 
of  the  lesion.  And  as  the  most  frequent  of  all  invaginations  are 
those  of  the  ileum  and  caecum  into  the  colon,  or  those  at  the  in- 
ferior portion  of  the  ileum,  it  is  at  the  lower  part  of  the  belly,  and 
generally  passing  in  direction  from  left  to  right,  and  in  the  right 
iliac  fossa,  that  the  swelling  is  detected.  The '  malady  occurs  at 
all  ages.     It  is  often  preceded  by  diarrhoea. 

The  course  invagination  pursues  is  rapid.  The  acute  inflam- 
mation it  occasions  soon  leads  to  a  fatal  termination,  or  the  patient 
dies  generally  in  less  than  a  week  after  the  occurrence  of  the  acci- 
dent, utterly  prostrated.  Yet  the  records  of  medicine  furnish  us 
with  instances  in  which  life  has  been  prolonged  for  months.  The 
cases  which  get  well  recover  either  gradually  after  the  invaginated 
bowel  has  been  discharged,  or,  in  very  rare  instances,  more  quickly 
by  the  inverted  bowel  righting  itself. 

As  regards  other  forms  of  intestinal  obstruction,  they  are,  with 
our  present  knowledge,  undistinguishable  from  one  another. 
However  desirable  it  might  be  on  therapeutic  grounds  to  be 
able  to  diagnosticate  a  twist  of  the  intestine,  or  its  blocking  up 
by  hardened  fseces  or  gall-stones,  or  its  strangulation  by  bands  or 
by  rents  in  the  mesentery ;  however  desirable  to  know  whether, 
if  medical  means  do  not  bring  relief,  the  hazardous  operation  of 
laying  open  the  belly  may  be  attempted  with  some  hope  of  suc- 
cess, or  whether  the  impediment  is  not  even  to  be  removed  by 
such  a  mode  of  succor, — it  must  be  confessed  that  there  are  no 


526  MEDICAL    DIAGNOSIS. 

positive  signs  which  enable  us  to  decide  on  the  nature  of  the 
obstacle. 

Yet  there  are  sometimes  circumstances  in  the  case  which  may 
help  to  a  correct  decision.  For  example,  if  the  complaint  occur 
in  one  who  has  suffered  from  the  passage  of  gall-stones,  it  is  likely 
that  a  large  concretion  of  this  kind  has  been  arrested  in  its  passage 
through  the  intestine,  and  is  the  cause  of  the  mischief.  Should 
the  disorder  be  encountered  in  a  person  over  forty  years  of  age, 
who  has  had  before  attacks  of  constipation  almost  invincible; 
who  at  all  times  has  difficulty  in  voiding  the  contents  of  the 
tube;  whose  fasces  present  peculiarities  in  shape  and  size,  and  are 
sometimes  mixed  with  blood ;  whose  health  has  been  gradually 
breaking;  whose  abdomen  is  much  distended  and  yields  a  ringing 
tympanitic  resonance  on  percussion, — should  such  a  person  have  an 
attack  of  constipation  unusually  protracted,  attended  with  enor- 
mous distention  of  the  bowel,  and  in  which  the  remedies,  whether 
mechanical  or  medicinal,  that  hitherto  barely  procured  a  passage, 
now  fail  utterly,  it  would  not  require  much  sagacity  to  discern 
that  a  stricture  of  the  intestine,  probably  of  a  cancerous  kind,  is  the 
source  of  the  cruel  and  irremediable  suffering.  If,  in  addition  to 
the  symptoms  enumerated,  a  bougie  passed  into  the  rectum  meet 
in  its  course  with  a  decided  obstacle,  an  error  in  diagnosis  is  hardly 
possible.  When,  however,  the  stricture  is  not  accessible  to  in- 
strumental examination,  although  we  can  commonly  recognize  its 
presence,  we  cannot  fix  its  site.  The  distention  above  the  nar- 
rowed part  is  often  so  extreme  as  to  lead  to  displacement  of  the 
colon  and  to  an  almost  uniform  swelling  of  the  whole  abdomen, 
thus  baffling  all  attempts  at  determining  the  point  of  constric- 
tion. For  instance,  in  a  case  reported  by  Dr.  Albert  H.  Smith, 
the  enormously  dilated  colon  had  broken  loose  from  its  attach- 
ments and  concealed  the  rest  of  the  viscera.  It  was  in  several 
places  eighteen,  in  none  less  than  fifteen,  inches  in  circumference; 
and  fully  two  gallons  of  liquid  fasces  were  found  in  the  bowels.* 

In  the  other  kinds  of  obstruction  the  same  difficulty — although 
not  of  necessity  arising  from  the  same  cause — may  exist  in  de- 
termining with  certainty  the  location  of  the  lesion.  There  are, 
however,  a  few  circumstances  which  may  aid  us  in  arriving  at 

*  Proceedings  of  Pathological  Society  of  Philadelphia,  Dec.  1858,  vol.  i. 


DISEASES    OF    THE    LN'TESTTXES    AXD    PEEITOXEOL  527 

such  a  determination  :  one  is  the  interesting  fact  pointed  out  by 
Barlow,*  that  the  higher  up  the  obstruction  is  in  the  canal,  the 
nearer  therefore  to  the  stomach,  the  smaller  is  the  quautity  of 
urine  passed  ;  another  is  the  early  occurrence  of  the  vomiting  and 
the  want  of  stercoraceous  character  of  the  matters  ejected, — both 
of  which  render  it  likely  that  the  impediment  is  in  the  small 
intestine  and  remote  from  the  csecum.  Still  another  is  the  speedy 
presence  and  the  greater  severity  of  hiccough  when  the  mischief 
is  in  the  small  intestine.  Sometimes  the  patient  is  himself  aware 
of  the  exact  seat  of  the  cause  of  his  suffering ;  he  notices  that  the 
injecting  tube  or  the  enemata  seem  to  reach  a  certain  point  and 
go  no  farther;  so,  also,  with  the  rumbling  of  the  wind.  Again, 
these  borborygmi  are  especially  apt  to  occur  in  obstructions  of 
the  large  intestine,  and,  if  joined  to  tenesmus,  are  signs  of  some 
importance. 

The  position  of  the  pain,  too,  may  furnish  a  clue  to  the  position 
of  the  impediment.  If  this  be  in  the  small  intestine,  the  pain  is 
apt  to  be  chiefly,  if  not  entirely,  in  the  neighborhood  of  the  um- 
bilicus. Another  circumstance  on  which  some  stress  may  be  laid 
is  the  distention  of  the  intestine  above  the  point  of  intussusception. 
Indeed,  this  distention  may  occasion  a  visible  fulness,  sounding 
extremely  tympanitic  on  percussion;  at  times,  too,  a  slight  dulness 
is  found,  attended  with  some  resistance  at  or  immediately  above 
the  seat  of  the  obstruction.  But  with  reference  to  the  swelling 
and  the  tympanitic  dilatation  of  the  bowel  there  are — as  William 
Brintonf  sets  forth  in  his  extended  researches  on  the  subject — 
several  reasons  which  render  these  signs  uncertain  guides.  The 
distended  intestine  may  not  be  capable  of  being  traced  by  the  eye 
or  by  percussion,  owing  to  its  occupying  a  large  portion  of  the 
abdominal  cavity.  Moreover,  a  stoppage  at  the  descending  part 
of  the  large  intestine,  for  instance  at  the  sigmoid  flexure,  may  lead 
to  most  palpable  distention  of  the  cgecum,  and  to  pain  in  that 
region ;  while  pain  and  swelling  are  also  observed  in  the  same 
locality  in  obstructions  which  affect  the  small  intestine.  Thus, 
then,  there  are  several  modifying  circumstances  which  prevent  too 

*  Guy's  Hospital  Reports,  2d  Series,  vol.  ii.  Brinton  accepts  this  statement 
only  in  so  far  as  the  amount  of  vomiting,  which  is  apt  to  be  greatest  when  the 
obstruction  is  high  up,  influences  the  amount  of  urine  passed. 

f  Croonian  Lectures,  and  work  on  Intestinal  Obstruction. 


528  MEDICAL    DIAGNOSIS. 

much  importance  being  attached  to  any  of  the  signs  mentioned  as 
proofs  of  the  seat  of  the  obstacle;  for,  with  the  exception  of  a 
tumor  dull  on  percussion  and  resistant  to  the  touch,  there  is 
nothing  absolutely  indicative  of  the  lesion  being  at  a  particular 
spot.  And  it  is  hardly  necessary  to  say  that  a  swelling  of  this 
kind  cannot  always  be  found. 

Internal  strangulation — as  by  a  band  acting  as  the  constricting 
agent,  or  a  diverticulum,  or  the  pedicle  of  an  ovarian  tumor — has 
its  seat  almost  constantly  in  the  small  intestine.  Hilton  Fagge,* 
who  has  ably  investigated  the  subject,  considers  these  symptoms  as 
significant  and  as  warranting  a  diagnosis  of  internal  constriction : 
the  sudden  onset  of  the  illness;  the  occurrence  of  collapse  at  its 
beginning;  the  comparatively  early  age  of  the  patient;  the  severity 
of  the  pain,  which  is  generally  referred  to  the  umbilicus;  the 
absence  of  external  or  of  discoverable  obturator  hernia;  the  ab- 
sence of  precursory  symptoms  and  of  visible  peristole, — such  as 
happen  in  stricture  and  contractions, — of  tumor,  of  hemorrhage, 
and  of  dysenteric  symptoms, — as  seen  in  intussusception, — and  of 
that  extreme  intensity  and  rapidity  of  the  disorder  which  charac- 
terize the  more  acute  forms  of  volvulus. 

In  referring  to  the  usual  seat  of  pain  and  swelling  in  the  right 
iliac  fossa,  and  to  the  difficulties  which  on  this  account  beset  the 
recognition  of  the  precise  site  of  the  hinderance,  one  source  of 
error  deserving  of  special  notice  was  not  mentioned.  The  pain 
and  the  fulness  in  this  region  may  be  caused  by  a  disease  of  the 
csecum  or  of  its  appendix.  Moreover,  affections  of  this  part  of 
the  alimentary  tract,  like  intestinal  occlusion,  give  rise  to  consti- 
pation which  is  most  obstinate  and  in  some  instances  incurable. 
Therefore  they  in  reality  enter  at  times  into  the  category  of  in- 
testinal obstructions,  from  the  other  varieties  of  which  they  are, 
under  such  circumstances,  undistinguishable  save  by  the  history 
of  the  case  and  the  different  sequence  of  the  phenomena.  The 
tumor  and  the  other  local  signs  do  not  follow  the  insuperable 
constipation,  but  they  precede  it.  Yet  if  the  patient  be  seen  for 
the  first  time  when  he  is  laboring  under  an  irremovable  in- 
testinal  impediment,  it  may  be  impossible  rightly  to  determine 
its  character. 

*  Guy's  Hospital  Keports,  3d  Series,  vol.  xiv. 


DISEASES    OF    THE    LSTESTIXES    AXD    PEEITONEUM.  529 

Habitual  Constipation. — We  are  often  called  upon  to 
remedy  a  sort  of  constipation  which  is  very  different  from'  that  of 
an  intestinal  obstruction.  It  is  a  chronic  state,  unattended  under 
ordinary  circumstances  with  urgent  symptoms  of  any  kind.  Still, 
it  is  an  annoying  disorder,  and  so  prevalent  that  there  is  hardly  a 
person,  among  the  thousands  who  lead  sedentary  lives,  who  does 
not  suffer  or  has  not  suffered  from  it.  The  symptoms  encountered, 
independently  of  the  rare  and  difficult  fsecal  evacuations,  are  head- 
ache, giddiness,  sluggishness  of  the  mind,  a  want  of  the  natural 
appetite,  and,  joined  as  the  complaint  not  unfrequently  is  to  de- 
rangement of  the  stomach  and  of  the  biliary  secretion,  digestive 
disturbances  and  a  sallow  complexion.  In  women  there  are  also 
often  added  to  the  list  of  evils  to  which  costiveness  gives  rise, 
neuralgic  pains,  palpitation  of  the  heart,  cold  feet  and  hands. 
Infrequent  evacuation  of  the  bowels  does  not  always  produce 
such  unpleasant  consequences.  It  may,  indeed,  in  individual 
cases  be  compatible  with  perfect  health ;  for  what  is  costiveness 
in  one  person  may  be  a  natural  state  in  another.  But  when  the 
bowels  are  acting  less  frequently  than  is  their  wont,  the  disagree- 
able symptoms  mentioned  are  apt  to  arise.* 

Habitual  constipation  is  produced  by  various  causes.  It  may 
be  brought  about  by  the  peculiar  nature  of  the  diet.  It  may 
depend  upon  a  deficiency  or  a  faulty  composition  of  the  intestinal 
secretions,  or  upon  disorders  of  those  neighboring  glands  which 
pour  their  secretions  into  the  intestines.  It  may  result  from  im- 
paired power  of  the  bowel  to  propel  its  contents,  the  consequence 
either  of  some  mechanical  interference  with  its  action,  or  of 
nervous  influences,  or  of  exposure  to  the  poisonous  effects  of  cer- 
tain substances,  as  of  lead.  To  particularize  the  numerous  con- 
ditions which  furnish  illustrations  of  each  of  these  different  causes 
would  be  tedious,  and  would  serve  no  useful  purpose.  I  shall 
select  only  a  few  for  special  notice. 

We  have  often  to  treat  constipation  in  those  who  are  dyspeptic 
and  suffer  from  piles.  In  them  there  is,  in  all  probability,  some 
congestion  of  the  portal  system,  and  not  unfrequently  a  constant 
derangement  of  the  flow  of  blood  through  the  liver.     The  normal 

*  In  the  American  Journal  of  the  Medical  Sciences,  Oct.  1874,  a  case  is 
reported  in  which  the  constipation  lasted  eight  months  and  sixteen  days. 

34 


530  MEDICAL    DIAGNOSIS. 

secretion  of  intestinal  juices  is  interfered  with,  healthy  bile  is  not 
supplied,  and  thus  costiveness  results.  A  similar  congestion  of 
the  intestinal  mucous  membrane  has  its  share  in  producing  the 
constipation  which  is  encountered  in  diseases  of  the  heart.  Some- 
times, however,  enough  healthy  fluid  is  poured  out  within  the  intes- 
tine; yet  there  is  a  deficiency,  because  the  inclination  to  go  to  stool 
is  resisted,  and  the  liquid  that  has  been  mixed  with  the  matter  to 
be  voided  is  reabsorbed.  In  women  who  neglect  the  calls  of  nature 
from  carelessness  or  because  circumstances  prevent  their  being 
obeyed  at  the  proper  time,  this  is  a  common  cause  of  constipation. 

The  influence  of  the  nervous  system  on  the  alimentary  tube  is 
shown  by  the  confined  state  of  the  bowels  which  attends  excessive 
intellectual  exertion  and  violent  emotions.  And  when  these  states 
are  protracted,  they  lead  to  a  permanent  and  annoying  debility  of 
the  intestine.  The  colon  especially  becomes  torpid  in  its  action, 
and  all  the  evil  results  of  constipation  show  themselves  in  their 
most  marked  degree.  Not  that  an  atony  of  the  bowel  is  always 
due  to  psychical  agencies.  Any  disorder  which  induces  loss  of 
power  in  the  muscular  fibres  may  give  rise  to  it.  We  find  it 
where  the  blood  is  watery  and  deficient  in  red  corpuscles,  and  in 
those  who  lead,  as  far  as  bodily  exertion  is  concerned,  a  sluggish 
life.  In  some  cases — fortunately  rare — the  weak  intestine  dis- 
tends greatly,  and  becoming,  as  above  explained,  unable  to  propel 
the  accumulated  fseces,  insuperable  constipation  occurs. 

The  same  complete  paralysis  of  the  tube,  attended  with  the 
same  unfortunate  consequences,  may  be  brought  about  by  chronic 
lesions  of  the  brain  or  spinal  cord.  Yet  the  inveterate  consti- 
pation which  is  so  constant  an  accompaniment  of  these  states  is 
partly  owing  to  the  powerless  condition  of  the  abdominal  muscles. 

Among  the  different  organic  changes  in  the  intestine  which,  by 
interfering  mechanically  with  the  peristaltic  wave  and  the  onward 
transmission  of  the  fseces,  set  up  constipation,  we  find  distention 
of  the  tube,  with  atrophy  of  the  muscular  fibres ;  various  infiltra- 
tions into  the  walls,  producing  a  narrowing  of  the  calibre ;  and 
adhesions  between  the  serous  coats  of  the  intestines,  or  between 
these  viscera  and  the  parietes.  Of  the  first,  it  need  only  be  said 
that  the  symptoms  are  due  to  the  same  paralyzed  condition  of  the 
intestine,  whether  complete  or  incomplete,  which  has  been  just 
considered,  and  which  has  been  dwelt  upon  more  at  length  when 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        531 

discussing  diseases  of  the  csecum,  and  intestinal  obstruction.  The 
second  group  embraces  those  infiltrations  which  result  from 
inflammations,  and  new  growths  of  different  kinds  which  lead 
to  strictures. 

The  former  of  these  are  recognized,  as  far  as  they  can  be  with 
certainty,  by  the  history  of  the  case.  The  latter  present  peculi- 
arities in  the  form  and  size  of  the  fseces,  distention  of  the  bowels 
above  the  seat  of  the  narrowing,  vomiting,  attacks  of  colic, 
gradual  wasting  and  exhaustion ;  besides  which,  extreme  costive- 
ness,  deepening  gradually  into  invincible  constipation,  furnishes  a 
key  to  the  grievous  nature  of  the  affection. 

When  the  constipation  arises  as  the  result  of  peritoneal  adhe- 
sions, there  are  sometimes  signs  in  the  case — such  as  tenderness 
at  a  particular  spot  from  still  existing  inflammation,  or  partial 
distention  or  retraction  of  the  abdomen — which  point  out  its 
nature.  In  the  absence  of  these,  the  history  is  our  only  guide, 
except  in  those  instances  in  which,  as  Dr.  Bright*  first  informed 
us,  a  peculiar  sensation  is  communicated  to  the  touch,  varying 
between  the  crepitation  produced  by  emphysema  and  the  feel 
derived  from  bending  new  leather  in  the  hand. 

Thus,  a  protracted  state  of  constipation  may  be  due  to  several 
causes,  some  of  which  are  of  very  serious  character.  And  this 
only  proves  how  important  it  is  to  look  further  than  the  mere 
constipation ;  how  necessary  in  every  case  to  endeavor,  as  nearly 
as  possible,  to  arrive  at  the  determining  cause  of  the  imperfect  or 
difficult  alvine  evacuations.  Still,  it  is  often  impossible  to  assign 
any  one  cause,  because  the  complaint  is,  in  fact,  dependent  upon 
the  union  of  several  of  those  which  have  been  mentioned.  More- 
over, we  must  not  forget  that  a  constipated  state  is  often  joined  to 
affections  of  the  stomach  or  the  liver,  and  our  treatment  for  the 
habitual  constipation  should  merge  into  that  of  the  disorder  of 
which  the  constipation  is  a  symptom. 

Disorders  in  which  Morbid  Discharges  from  the  Bowels  occur, 

Matters  very  unlike  the  healthy  alvine  evacuations  are  often 

voided  from  the  intestinal  canal ;  loose  watery  stools,  large  quan- 

*  Cases  illustrative  of  the  Diagnosis  of  Adhesions  and  other  Morbid  Changes 
of  the  Peritoneum,  Med.-Chir.  Trans.,  vol.  xix. 


532  MEDICAL    DIAGNOSIS. 

tities  of  mucus,  pus,  or  blood,  may  be  discharged.  I  shall  here 
describe  the  disorders  which  occasion  these  discharges. 

Diarrhoea. — The  remark  made  of  constipation  is  equally 
applicable  to  diarrhoea.  Both  states  occur  as  an  accompaniment 
to  a  vast  number  of  diseases  which  present  symptoms  more  char- 
acteristic than  the  confined  or  loose  state  of  the  bowels.  At  this 
place,  diarrhoea  will  be  merely  treated  of  as  we  meet  with  it  con- 
stituting, as  far  as  can  be  ascertained,  the  entire  ailment,  or  at  all 
events  by  far  its  most  prominent  symptom.  There  are  several 
varieties  of  diarrhoea.  Difference  in  time  gives  rise  to  marked 
varieties, — to  an  acute  and  to  a  chronic  form. 

Acute  Diarrhoea. — Acute  diarrhoea  proceeds  from  more  than 
one  cause:  it  may  be  excited  by  the  irritating  character  of  the 
food  taken,  or  by  impure  water;  it  may  be  brought  about  by 
the  morbid  nature  of  the  secretions  poured  into  the  intestines;  it 
may  be  owing  to  atmospheric  influences, — to  heat,  to  moisture,  to 
contaminated  air;  it  may  be  caused  by  chilling  of  the  surface 
of  the  body,  or  by  irritant  poisons,  retained  fasces,  or  worms. 
It  may  be  occasioned  by  pyaemia  and  septicaemia,  by  reflex  irrita- 
tion, as  in  dentition,  or  by  mental  emotions,  and  especially  by  fear. 
Sometimes  it  occurs  in  an  epidemic  form  due  to  some  unknown 
miasm.  Its  symptoms  are  thirst;  abdominal  uneasiness;  griping 
pain  in  the  bowel;  pallor;  slight  debility;  and  frequent  fluid 
alvine  evacuations,  which  may  finally  become  almost  colorless. 

In  the  diarrhoea  caused  by  a  debauch  or  by  indigestible  food, 
nausea  and  a  furred  tongue  are  added  to  the  list  of  symptoms 
mentioned.  This  kind  of  diarrhoea  is  generally  of  very  short 
duration.  It  is  an  effort  of  nature  to  get  rid  of  obnoxious  matter; 
and  when  this  is  effected,  the  looseness  of  the  bowels  ceases  of 
itself.  The  discharges  from  the  intestines  are,  therefore,  rather  to 
be  favored  than  suppressed ;  and  we  can  greatly  aid  the  recovery 
by  enjoining  abstinence  from  food. 

The  variety  of  diarrhoea  under  consideration  sometimes  goes 
hand  in  hand  with  a  disturbance  of  the  biliary  functions,  and  the 
stools  discharged  are  fetid,  and  present  the  appearance  generally 
described  as  bilious.  This  "  bilious  diarrhoea,"  too,  is  not  un- 
common in  persons  whose  livers  are  habitually  sluggish.  It  is 
also  frequently  encountered  during  the  hot  months  of  summer 
and  early  in  the  autumn,  and  has  a  tendency  to  run  on. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        533 

Owing  to  the  extreme  rarity  with  which  an  opportunity  offers 
to  examine  it,  the  state  of  the  mucous  membrane  during  an  attack 
of  acute  diarrhoea  is  not  accurately  determined.  In  some  instances 
decided  redness,  swelling,  cedema,  and  other  evidences  of  acute 
inflammation  have  been  found.  But  these  were  cases  in  which 
during  life  the  symptoms  had  been  severe ;  in  fact,  more  or  less 
those  of  an  inflammation, — pain,  considerable  soreness  to  the 
touch,  and,  what  is  not  ordinarily  met  with  in  diarrhoea,  marked 
heat  of  skin  and  excited  pulse.  These  graver  kinds  of  acute 
diarrhcea,  or  rather  of  muco-enteritis  with  diarrhoea  as  a  symp- 
tom, are  often  the  result  of  irritant  poisoning.  They  are  still 
more  usually  observed  as  secondary  disorders  in  typhoid  fever 
and  in  the  exanthemata.  In  lighter  cases,  the  mucous  membrane 
is  simply  injected,  somewhat  tumid,  and  the  epithelium  has  des- 
quamated freely.  This  kind  of  "acute  intestinal  catarrh"  is  very 
common  as  the  result  of  the  influence  of  cold,  or  of  acrid  drinks 
and  unripe  fruit. 

Chronic  Diarrhoea. — In  chronic  diarrhcea  the  lesions  encoun- 
tered are  much  more  marked  than  they  ever  are  in  the  acute  form. 
The  mucous  membrane  is  tumid  and  discolored ;  its  follicles  are 
not  unfrequently  ulcerated.  Chronic  looseness  of  the  bowels 
originates  in  a  diarrhcea  which  is  permitted  to  continue,  either 
from  neglect  or  because  the  patient  remains  for  a  long  time  ex- 
posed to  the  original  cause.  But  the  disorder,  no  matter  under 
what  circumstances  it  originated,  is  apt  to  prove  rebellious,  and 
to  end  by  breaking  down  the  constitution.  When  of  long  stand- 
ing, the  patient  becomes  gradually  weaker  and  weaker,  and  more 
and  more  emaciated.  The  abdomen  is  sunken;  the  expression  of 
the  face  despondent;  the  complexion  pale;  the  eyes  are  surrounded 
by  a  dark  ring.  The  character  of  the  discharges  is  very  various. 
They  are  often  dark-colored  and  very  offensive.  Sometimes  the 
looseness  of  the  bowels  alternates  with  an  opposite  condition ;  but 
the  irritability  of  the  intestines  never  intermits. 

This  morbid  excitability  of  the  intestinal  tube  is  especially 
brought  about  in  persons  of  nervous  temperament  and  of  dis- 
sipated habits.  The  abuse  of  purgatives,  too,  induces  it,  and  in 
consequence  chronic  diarrhcea  is  not  an  uncommon  result  of  the 
cathartic  pills  which  many  of  the  patrons  of  quack  medicines 
habitually  swallow. 


534  MEDICAL    DIAGNOSIS. 

But  perhaps  the  most  persistent  irritability  of  the  intestines  is 
found  in  the  diarrhoea  to  which  soldiers  are  so  liable,  and  which 
is  apt  to  pass,  no  matter  what  its  beginning,  into  the  chronic  form 
of  the  disease.  And  this  complaint,  which  is  generally  associated 
with  a  morbid  state  of  the  large  intestine  as  well  as  of  the  small, 
which  combines  therefore  some  of  the  features  of  chronic  dysentery 
with  those  of  chronic  diarrhoea,  is  one  that  often  clings  to  its  victim 
through  life:  many  a  soldier,  in  truth,  escapes  the  bullet  and  the 
sword,  only  to  die  of  the  intestinal  affection  long  after  his  return 
to  his  home. 

The  causes  of  the  diarrhoea  in  soldiers  are  the  ordinary  causes  of 
chronic  diarrhoea  already  mentioned,  favored  in  their  development 
by  fatiguing  marches,  by  want  of  personal  cleanliness,  by  defect- 
ive diet,  by  the  exposure  in  camp,  by  hot  weather,  by  malaria, 
and  in  many  instances  by  a  specific  epidemic  poison  in  the  atmos- 
phere. To  this  origin  are  chiefly  referred  the  numerous  instances 
of  atonic  diarrhoea  which  happened  among  the  British  troops  in 
the  Crimea.*  During  our  civil  war  we  did  not  escape  this  scourge 
of  armies.  Irrespective  of  the  causes  always  acting  whenever 
large  numbers  of  men  are  collected  together  for  warlike  operations, 
scurvy  is  stated  to  have  been  a  prolific  source  of  the  thousands 
of  cases  of  diarrhoea  which  occurred  in  the  army  during  the  past 
conflict.t 

The  chronic  diarrhoea  among  soldiers  is  not  materially  differ- 
ent in  its  symptoms  from  chronic  diarrhoea  of  civil  life,  except 
that  perhaps  we  find  more  frequently  thickening  and  ulceration 
of  the  colon ;  more  frequently,  therefore,  stools  containing  pus, 
and  more  of  the  evidences  of  chronic  dysentery  than  usually 
coexist  with  what  is  known  as  chronic  diarrhoea.  Then,  the  affec- 
tion is  very  often  witnessed  as  a  complication  of  other  disorders. 
Two-thirds  of  the  fever  patients  received  in  the  hospitals  at  Con- 
stantinople during  a  long  period  of  the  Crimean  war  were  affected 
with  diarrhoea  or  with  dysentery.  Diarrhoea  was  so  very  general 
that  nearly  all  disorders  were  preceded  by  acute  diarrhoea  and  ter- 

*  Blue  Book,  Medical  and  Surgical  History  of  the  "War  against  Kussia, 
vol.  ii.  p.  101. 

t  Woodward,  Outlines  of  the  Chief  Camp  Diseases,  p.  253;  see  also  the 
elaborate  analysis  of  the  alvine  fluxes  in  vol.  ii.  of  the  splendid  "  Medical  and 
Surgical  History  of  the  War  of  the  Rebellion, !"  Washington,  1879. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        535 

minated  in  chronic  diarrhoea.*  To  any  one  who  had  opportuni- 
ties of  observing  cases  of  the  Chickahominy  fever  and  diarrhoea 
so  prevalent  during  General  McClellan's  peninsular  campaign, 
a  parallel  will  at  once  occur. 

But  chronic  diarrhoea,  as  the  practitioner  of  medicine  commonly 
sees  it,  is  not  always  so  strictly  an  idiopathic  ailment  as  are  for 
the  most  part  the  forms  of  the  malady  just  discussed.  It  is  often 
attendant  on  general  constitutional  affections,  or  on  abdominal 
diseases  which  have  led  to  a  secondary  disorder  of  the  secretions, 
or  even  of  the  coats  of  the  intestine.  Thus,  we  find  chronic  loose- 
ness of  the  bowels  in  scurvy,  in  pyaemia,  in  Bright's  disease,  in 
scrofula  of  the  mesenteric  glands,  and  in  tuberculosis.  In  the 
last  of  these  complaints  the  diarrhoea  may  be  occasioned  by 
changes  in  the  secretions  of  the  intestinal  glands  ;  but  it  is  not 
seldom  dependent  upon  a  true  tubercular  disease  of  the  intestines, 
which,  like  the  disease  of  the  lung,  leads  to  softening  and  ulcer- 
ation. The  discharges  are  generally  copious  and  very  offensive. 
They  show  traces  of  blood,  and  contain  frequently  undigested  food. 
The  diarrhoea  is  continuous  and  intractable;  the  abdomen  is  re- 
tracted, and  presents  spots  very  tender  to  the  touch.  There  are 
marked  fever  and  emaciation,  and  there  may  be  severe  intestinal 
hemorrhage.  Yet,  after  all,  only  the  signs  of  tubercle  elsewhere 
furnish  any  positive  indications  by  which  the  true  nature  of  the 
wasting  malady  can  be  discerned. 

In  the  chronic  diarrhoea  of  strumous  children  there  is  sometimes 
a  scrofulous  infiltration  into  the  intestinal  walls,  sometimes  marked 
scrofulous  enlargement  of  the  mesenteric  glands,  sometimes  both, 
but  in  some  cases  neither.  Improper  nourishment  may  be  the 
exciting  cause  of  the  continued  purging;  for  do  we  not  see  even 
healthy  infants,  surrounded  by  every  comfort  and  every  care  that 
wealth  can  procure,  when  unsuitably  fed,  or  weaned  too  soon, 
suffer  from  continued  irritation  of  the  alimentary  tube? 

At  times  chronic  diarrhoea  assumes  an  intermittent  type,  and 
its  malarial  nature  is  clearly  proved  by  the  readiness  with  which 
the  disorder  yields  to  quinine.f     In  this  respect  malarial  diar- 


*  Baudens,  La  Guerre  de  Crimee. 

-j-  See   contribution   by  Dr.  Sanford  B.  Hunt  on   Diarrhoea,  in   Medical 
Memoirs  of  TJ.  S.  Sanitary  Commission,  p.  306. 


536  MEDICAL    DIAGNOSIS. 

rhcea  differs  from  cases  of  diarrhoea  we  sometimes  encounter,  in 
which  the  pain  and  discharges  come  on  at  an  early  hour  of  the 
day  and  cease  toward  evening  and  during  the  night. 

Another  form  of  looseness  of  the  bowels  is  the  membranous. 
Here  the  discharges  show  shreds  of  membrane,  either  in  con- 
nection with  the  loose  stools,  or  sometimes  in  such  quantities  that 
the  whole  mass  voided  seems  to  consist  of  them.  Griping  pains 
and  tenderness  usually  precede  this  kind  of  diarrhoea,  which  may 
happen  in  attacks  of  a  subacute  form,  or  as  a  persistent  and  very 
obstinate  disorder:  the  former  variety  is  the  more  common.  The 
faecal  discharges  are  loose,  but  occasionally  for  a  time  there  is 
constipation.  The  disease  is  often  associated  with  peculiar  hys- 
terical symptoms.  The  so-called  membranes,  in  this  membranous 
enteritis,  contain  a  large  amount  of  mucus,  as  I  have  elsewhere 
described.* 

Dysentery. — Frequent  and  painful  passages  of  mucus  mixed 
with  blood,  accompanied  with  straining  and  bearing  down,  are  the 
characteristic  symptoms  of  dysentery.  In  this  acute  form  we  find 
thirst,  restlessness,  and  heat  of  skin  superadded;  and  sometimes, 
in  severe  cases,  especially  when  the  disease  prevails  epidemically, 
those  symptoms  of  prostration  which,  grouped  together,  are  com- 
monly designated  as  typhoid. 

Acute  Dysentery. — The  acute  disorder  is  at  times  ushered  in  by 
a  chill ;  at  times  it  is  preceded  by  diarrhoea.  The  fever  which 
attends  it  is  not  generally  intense.  It  is  the  exception  to  find  a 
hard,  rapid  pulse,  and  a  very  hot,  dry  skin;  and  in  light  cases 
the  pulse  is  but  little  excited,  and  the  temperature  only  slightly 
raised.  More  or  less  pain  is  always  present.  It  has  its  seat 
mostly,  but  not  invariably,  at  some  part  of  the  colon,  and  this  is 
tender  on  pressure.  It  is  not  constant,  but  intermitting  and 
shifting,  and  is  often  accompanied  by  a  disagreeable,  weighty  feel- 
ing near  the  anus,  which  causes  a  continual  desire  to  go  to  stool. 
Yet  no  relief  follows  the  frequent  attempts  at  defecation;  the 
violent  straining  only  adds  to  the  discomfort  of  the  patient. 

The  matters  voided  are  small  in  quantity.  They  consist  of 
blood  mixed  with  mucus;  but,  like  nearly  all  of  the  so-termed 
mucous  discharges,  they  are  composed  not  simply  of  mucus,  but 

*  American  Journal  of  the  Medical  Sciences,  Oct.  1871. 


DISEASES    OF    THE    INTESTINES    AXD    PERITONEUM.        537 

also  of  pus  corpuscles,  exudation  globules,  granules,  and  large 
quantities  of  cast-off  epithelium.  They  are  in  some  cases  highly 
offensive,  and  resemble  the  washings  of  meat ;  in  others,  they  are 
like  jelly,  or  greenish  in  color.  They  do  not  contain  faeces,  or 
only  here  and  there  small,  firm  lumps  of  fsecal  matter :  hence  we 
may  justly  say  that,  for  the  most  part,  dysentery  is  in  reality 
attended  with  constipation.  When  the  dysenteric  inflammation 
subsides,  the  bowels  are  unloaded  of  their  contents :  in  conse- 
quence, the  passage  of  quantities  of  small,  hard  masses  of  faeces  is 
generally  a  sign  that  the  acute  malady  is  inclining  to  a  favorable 
termination.  Sometimes  the  stools  are  very  dark  and  slimy  and 
have  a  putrid  odor,  and  here  and  there  pieces  of  sloughed-off 
tissue  can  be  detected.  This  kind  of  stool  marks  the  diphtheritic 
or  gangrenous  variety  of  the  malady,— though  it  is  not  constant 
even  in  this, — and  is  apt  to  be  associated  with  vomiting,  with  hic- 
cough, and  with  great  depression. 

How  long-  it  will  take  for  the  disorder  to  run  its  course,  or 
whether  the  acute  disease  will  pass  into  chronic  dysentery,  cannot 
be  foretold.  Generally  this  is  not  its  termination ;  it  very  often 
ends,  within  a  week  from  its  commencement,  in  recovery.  But 
severe  cases  occur  which  are  of  much  shorter  duration,  and' in 
which  the  symptoms  hasten  on  to  complete  prostration  and  death 
takes  place  early  in  the  malady.  In  these  frightful  cases — most 
frequently  encountered  in  epidemics  and  where  the  distemper  pre- 
vails among  large  bodies  of  men — collapse  may  happen  with 
almost  the  same  rapidity  as  it  does  in  malignant  cholera. 

Dysentery  is  essentially  a  disease  of  hot  climates.  It  is  very 
common  in  this  country  in  summer  and  in  autumn.  Eating  green 
fruits,  exposure  to  a  chilly  night  after  a  hot  day,  and  sleeping  on 
damp  ground,  are  prolific  exciting  causes.  It  is  occasionally  found 
in  combination  with  malarial  fevers,  adding  greatly  to  their  danger, 
or  with  undoubted  evidence  of  scurvy.  The  immediate  cause  of 
most  of  the  symptoms  is  the  inflammation  of  the  large  intestine, 
and  especially  of  the  portion  which  commonly  bears  the  brunt  of 
the  disorder, — the  descending  colon.  Yet  in  many  cases  of  dys- 
entery we  see  phenomena  manifested  which  are  clearly  not  to  be 
accounted  for  solely  by  the  local  morbid  appearances  detected  after 
death,  and  which  show  that  dysentery  is  often  something  more 
than  mere  inflammation  of  the  colon.     In  truth,  inflammation  of 


538  MEDICAL    DIAGNOSIS. 

the  colon  may  give  rise  to  the  symptoms  of  acute  diarrhoea;  for 
it  is  a  great  mistake  to  suppose  that  the  cause  of  diarrhoea  is  only 
to  be  sought  in  some  abnormal  change  in  the  small  intestines. 
Thus,  colitis  is  not  always  dysentery;  and  dysentery  is  often  more 
than  mere  colitis. 

But  whether  we  believe  dysentery  to  be  simply  inflammation  of 
the  colon;  or  an  inflammation  of  the  colon  arising  from  a  dis- 
eased state  of  the  blood,  and  forming,  therefore,  only  part  of  a 
general  malady ;  or  believe  it  to  be  sometimes  one,  sometimes  the 
other, — we  find  that  it  presents  peculiarities  which  render  it  easy 
of  recognition  at  the  bedside. 

Yet  we  should  take  good  care  to  ascertain  that  the  supposed 
characteristic  tenesmus  and  bloody  discharges  are  not  really  owing 
to  piles  or  to  morbid  growths  in  the  rectum,  or  to  its  ordinary 
limited  inflammation.  In  the  latter  case,  there  is  much  pain  when 
the  hardened  fseces  are  discharged,  the  rectum  is  forced  down 
during  the  efforts,  the  sphincter  contracts  spasmodically.  Strangury 
and  hemorrhoids  are  not  uncommon  symptoms ;  and,  as  the  con- 
sequence of  the  inflammation  extending  to  the  parts  around  the 
anus,  an  abscess  may  follow. 

There  is  less  danger  of  confounding  enteritis  or  diarrhoea  with 
dysentery,  for  symptoms  exist  in  the  latter  which  do  not  belong 
to  either  of  the  former.  Enteritis  has  fever;  so  has  dysentery, 
though  the  febrile  disturbance  is  not  often  of  a  high  grade.  And, 
independently  of  the  differences  arising  from  the  absence  of 
the  peculiar  discharges  of  dysentery,  the  pulse  of  enteritis  is 
small,  tense,  and  quick ;  that  of  dysentery,  if  the  febrile  action  be 
marked,  full  and  rapid.  Diarrhoea  differs  from  dysentery  by  the 
liquid  faecal  evacuations,  and  by  the  fact  that  neither  tenesmus, 
nor  bloody  stools,  nor  discharges  of  mucus  occur.  Yet  in  practice 
we  meet  with  cases  which  commence  with  diarrhoea  and  end  with 
dysentery,  or  begin  with  dysenteric  symptoms  and  terminate  in 
diarrhoea,  and  in  which  it  becomes,  therefore,  puzzling  to  say 
whether  we  are  dealing  with  the  former  or  with  the  latter  disorder. 

Chronic  Dysentery. — In  chronic  dysentery  this  mingling  of  the 
two  complaints  is  especially  apt  to  happen.  We  rarely  see  chronic 
dysentery  without  chronic  diarrhoea.  At  all  events,  we  seldom 
find  instances  of  the  former  in  which  the  tenesmus  and  the  dis- 
charge of  blood  and  mucus  mixed  with  pus  are  not  accompanied 


DISEASES    OF    THE    INTESTINES    AND    PEEITONEUM.        539 

by  frequent  loose  alvine  evacuations,  by  griping,  by  the  same 
gradual  wasting  and  the  same  irritability  of  the  bowels  as  are 
encountered  in  chronic  diarrhoea;  nay,  the  symptoms  of  the  latter, 
and  the  difficulty  of  determining  the  presence  of  pus  when  mixed 
with  fluid  fasces,  may  so  obscure  the  true  nature  of  the  malady 
that  what  has  been  regarded  as  chronic  diarrhoea  turns  out,  at  the 
autopsy,  to  be  chronic  dysentery.  The  mucous  membrane  of  the 
colon  is  found  to  be  extensively  inflamed  ;  its  texture  altered  and 
irregularly  thickened ;  its  surface  riddled  with  ulcers.  In  such 
cases  the  patient  goes  on  steadily  losing  flesh ;  but  no  pain  on 
pressure  or  localized  distress  exists  to  denote  the  ravages  the  dis- 
ease is  making  in  the  alimentary  tube.' 

The  prognosis  is  never  very  favorable.  To  say,  indeed,  that  it 
is  wholly  unfavorable,  would  hardly  be  to  overrate  the  serious 
character  of  the  disease.  Many  die  from  exhaustion ;  others,  in 
consequence  of  abscess  of  the  liver,  which  chronic  as  well  as 
acute  dysentery  may  induce. 

Intestinal  Hemorrhage,  or  Melaena. — The  discharge  of 
blood  in  large  quantities  from  the  bowels  is  not  apt  to  occur  in 
dysentery.  It  is  much  more  common  as  the  result  of  a  mechanical 
hinderance  to  its  flow  through  the  liver,  as  in  cirrhosis,  or  of  dis- 
ease of  the  heart,  or  of  a  depraved  state  of  the  circulating  fluid, — 
such  as  exists  in  typhus  fever,  in  yellow  fever,  in  scurvy,  or  in 
purpura.  Occasionally  the  bleeding  proceeds  from  a  fungoid 
growth  in  the  intestine,  or  from  an  ulcer  in  the  duodenum  or  ileum, 
or  from  an  invagination,  or  from  faecal  impaction,  or  from  amyloid 
degeneration  of  the  mucous  membrane  of  the  bowel,  or  is  due 
to  a  disease  of  the  spleen,  or  to  the  bursting  of  an  aneurism. 
Rokitansky  informs  us  that  intestinal  hemorrhages  sometimes 
follow  extensive  burns  of  the  abdominal  parietes.  And  in  very 
young  infants,  a  discharge  of  blood,  both  by  the  mouth  and  by 
the  rectum,  is  not  unusual. 

The  blood  passed  by  stool  is  generally  of  dark  color,  like  tar. 
When  it  is  not,  we  may  fairly  infer  that  it  flows  from  the  lower 
part  of  the  intestine  and  has  not  had  much  chance  to  become  ad- 
mixed with  other  matters.  In  all  such  cases,  however,  we  must 
make  sure,  before  arriving  at  any  conclusion  as  to  the  source  of 
the  bleeding,  that  it  does  not  proceed  from  hemorrhoids.  The 
exact  seat  of  the  hemorrhage  cannot  be  determined;  nay,  blood 


540  MEDICAL    DIAGNOSIS. 

may  be  evacuated  by  the  bowel  and  not  be  poured  out  at  all  from 
the  intestine,  but  from  the  stomach.  In  some  instances  the  blood 
accumulates  in  the  bowel,  and  before  the  clots  moulded  to  its 
shape  are  discharged,  death  results.*  When  the  bleeding  pro- 
ceeds from  hemorrhoids  it  is  very  seldom  vicarious.f 

In  point  of  diagnosis  the  first  thing  to  determine  is,  that  what 
is  supposed  to  be  blood  is  really  blood.  Very  dark  bilious  stools, 
or  stools  blackened  by  iron,  may  mislead.  If  doubt  exist,  water 
should  be  poured  on  the  stool,  and,  when  blood  is  present,  a 
reddish  tinge  is  imparted  to  the  water ;  still  more  accurate  is  it 
to  examine  with  the  microscope  or  the  spectroscope. 

"We  next  have  to  ascertain  the  disease  with  which  the  intestinal 
hemorrhage  is  associated  ;  and  this  is  often  a  very  difficult  matter. 
We  must  lay  the  greatest  stress  on  the  history  of  the  case,  look 
for  the  complaints — of  which  most  have  been  above  mentioned — 
which  are  apt  to  give  rise  to  the  bleeding,  especially  investigating 
for  cirrhosis  of  the  liver;  searching  for  intestinal  ulcers  in  con- 
nection with  typhoid  fever  or  tuberculosis,  or  associated  with  the 
signs  of  a  disorder  of  digestion  in  a  duodenal  aifection;  or  exam- 
ining for  the  evidence  of  scurvy  in  the  gums  and  skin,  or  for 
purpura  with  its  characteristic  spots  and  other  symptoms,  or  for 
marked  splenic  enlargement,  the  result  of  chronic  malaria,  or 
perhaps  combined  with  bone  disease  or  syphilis  and  joined  to 
amyloid  degeneration  of  liver,  kidneys,  and  intestinal  walls,  and 
then  presenting  albuminous  urine  and  diarrhoea.  Embolism  of 
the  superior  mesenteric  artery  we  now  know  may  also  occasion 
intestinal  hemorrhage.  But  unless  we  have  with  the  bloody 
stools  marked  abdominal  pains,  peritoneal  exudation,  and  obvious 
causing  elements  of  embolism  or  signs  of  it  elsewhere,  the  diag- 
nosis is  most  uncertain. 

Fatty  Diarrhoea. — The  occurrence  of  cases  in  which  large 
quantities  of  fat,  mixed  or  pure,  are  voided  by  the  rectum,  is 
well  attested.  In  some  of  these  cases  oil  was  at  the  same  time 
passed  with  the  urine;  in  others  the  urinary  secretion  was  healthy; 
some  cases  ended  fatally,  others  in  recovery ;  some  were  found  to 


*  See  observations  of  Cheyne,  Dublin  Hospital  Reports,  vol.  i. ;    and  of 
Belcombe,  Medical  Gazette,  vol.  iv. 
f  Lee,  on  the  Rectum. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        541 

be  connected  with  a  disease  of  the  pancreas,  others  were  not;  in 
some  the  disorder  was  not  of  long  continuance,  while  in  others  it 
lasted,  with  intervals,  for  years.  Thus  the  morbid  state  with  which 
fatty  diarrhoea  is  associated  is  far  from  being  always  the  same. 

As  a.  rule,  the  occurrence  of  fatty  stools  is  "a  matter  of  serious 
concern.  The  recognition  of  the  malady  is  easy.  The  white, 
fatty  masses,  or  the  oily  matter  which  collects  on  the  discharges, 
are  soluble  in  ether,  and  are  readily  proved  to  be  fat  by  the  micro- 
scope; they  burn,  too,  like  fat,  with  a  flame.  In  some  instances 
the  bowels  are  very  constipated,  and  lumps  of  hard  fgeces  are 
discharged  along  with  the  fatty  substance.  This  happened  in  a 
marked  example  of  the  disorder  that  came  under  my  observation. 
The  patient,  a  man  twenty-six  years  of  age,  passed  a  considerable 
amount  of  fat  both  by  the  rectum  and  with  the  urine.  He  suf- 
fered much  from  digestive  disturbance,  from  constipation,  and 
from  weakness.  He  had  a  good  appetite,  but  a  dislike  to  fats 
of  any  kind.  In  his  case  there  was,  as  far  as  the  other  symptoms 
and  the  physical  signs  indicated,  no  tumor  in  the  region  of  the 
pancreas.  The  man's  condition  was  much  improved  by  the  ad- 
ministration of  cinchona  and  rhubarb;  but  whether  permanently 
or  not  I  cannot  say,  as  I  lost  sight  of  him. 

I  have  also  met  with  instances  of  fatty  diarrhoea  associated  with 
saccharine  diabetes  and  with  disease  of  the  pancreas. 

Diseases  attended  with  Vomiting  and  Purging. 

There  is  a  group  of  diseases  in  which  vomiting  and  purging 
are  very  prominent  symptoms.  It  embraces  those  disorders  in 
which  the  intestine  and  the  stomach  are  equally  involved.  To  this 
group  belong  some  affections  which  have  already  been  considered, 
which  begin  in  one  viscus  and  then  spread  to  the  other.  But 
those  in  which  both  are  primarily  affected  still  remain  to  be 
described.  The  most  important  of  them  are  the  various  forms  of 
cholera.  Now,  there  are  several  very  different  complaints  classed 
together  under  the  head  of  cholera.  Let  us  proceed  to  consider 
them  one  by  one. 

Cholera  Infantum. — And  first,  of  the  so-called  cholera  of 
infants.  It  is  an  endemic  in  the  larger  cities  of  the  United  States 
during  the  hot  months,  and  one  fraught  with  danger  to  all  young 


542  MEDICAL    DIAGNOSIS. 

children.     Hundreds  die  of  this  summer  complaint  every  year  in 
our  densely  populated  towns. 

It  begins  generally  with  diarrhoea.  "Vomiting  soon  follows; 
and  for  a  time  the  two  go  hand  in  hand;  but,  unless  the  case  be 
of  very  short  duration,  the  spontaneous  vomiting  ceases,  or  at  all 
events  gives  way  to  occasional  exacerbations  of  irritability  of  the 
stomach,  while  the  looseness  of  the  bowels  remains,  or  even  aug- 
ments. The  discharges  are  colorless,  or  yellowish,  or  greenish. 
There  is  thirst;  sometimes  fever.  The  abdomen  may  be  sunken 
or  swollen;  and  it  may  be  tender.  Sometimes  the  disease  runs 
its  course  within  three  or  four  days;  at  the  end  of  which  time 
the  child  dies,  worn  out  by  the  constant  vomiting  and  purging. 
More  generally  the  disorder  is  of  longer  duration ;  for  weeks  or  ■ 
for  months  it  continues,  the  diarrhoea  improving  and  then  re- 
turning with  redoubled  severity,  and  kept  up  or  increased  by  the 
irritation  of  teething.  The  irritability  of  the  intestinal  canal,  and 
the  utter  impossibility  of  retaining  enough  food  to  nourish  the 
wasting  body,  gradually  wear  out  the  system.  The  child  before 
death  is  wan  and  distressingly  emaciated ;  sometimes  suppression 
of  urine,  or  restlessness,  plaintive  cries,  rolling  of  the  head,  stra- 
bismus, coma, — the  symptoms  of  acute  hydrocephalus, — precede 
the  fatal  termination. 

Such  is  a  sketch  of  grave  and  intractable  cases.  Yet  many 
cases  are  far  from  being  so  desperate.  Under  judicious  treatment 
a  large  number  are  annually  saved.  Recoveries  would  bear  a 
still  higher  proportion  to  the  deaths,  were  it  not  that  the  greatest 
sufferers  from  the  disease,  the  children  of  the  poor,  are  unable  to 
obtain  the  means  most  certain  to  restore  them  to  health, — change 
of  air.  Cooped  up  in  crowded  neighborhoods,  surrounded  on  all 
sides  by  filth  rapidly  decomposing  under  the  burning  rays  of  the 
sun,  they  are  compelled  to  breathe  the  hot,  noxious  atmosphere 
which  has  been  the  chief  agent  in  generating  the  complaint. 

The  exact  pathology  of  the  disease  is  unknown.  The  careful 
researches  of  Lewis  Smith  have  familiarized  us  with  the  fact  that 
inflammation  of  the  whole  of  the  gastro-intestinal  tract,  with  en- 
largement of  the  solitary  glands,  and  even  of  Peyer's  patches, 
is  common.  But  whether  the  lesions  are  the  cause  or  the  conse- 
quence of  the  disorder  is  not  as  yet  settled.  The  diagnosis  is  as 
clear  as  the  pathology  is  doubtful.     Temporary  diarrhoeas  in  chil- 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        543 

dren  occurring  in  hot  weather  could  alone  be  mistaken  for  the 
disorder.  But  the  fact  that  they  are  temporary,  not  followed  by 
vomiting,  and  not  associated  with  the  grave  symptoms  of  ap- 
proaching collapse,  shows  us  the  difference. 

Cholera  Morbus. — Like  the  cholera  of  infants,  cholera  mor- 
bus is  a  disease  of  the  hot  season ;  yet  it  is  also  observed  at  other 
times  of  the  year.  But,  although  the  chief  predisposing  cause 
is  undoubtedly  heat,  there  is  generally  an  exciting  cause  which 
develops  the  disorder :  such  as  exposure,  checked  perspiration, 
drinking  large  quantities  of  ice-water,  or  imprudence  in  eating. 
The  attack  is  characterized  by  spasmodic  pains  in  the  abdo- 
men, by  cramps  in  the  legs,  by  rapid  loss  of  strength,  and  by 
repeated  vomiting  and  purging.  The  matter  ejected  both  from 
the  stomach  and  from  the  intestines  is  liquid,  and  contains  a 
large  quantity  of  bile.  In  truth,  the  affection  is  in  reality  a 
cholera,  a  flow  of  bile,  which  its  more  formidable  namesake, 
Asiatic  cholera,  is  not. 

The  disease  is  sometimes  preceded  by  colicky  pains,  nausea,  and 
rumbling  in  the  intestines.  More  generally  it  comes  on  suddenly. 
When  at  its  height,  the  cramps  in  the  calves  of  the  legs  cause  the 
muscles  to  rise  up  in  hard,  knotty  masses ;  the  stools  are  fetid  ;  the 
vomiting  is  constant;  the  thirst  is  great,  and  the  skin  is  cool  or 
cold.  But  the  patient  does  not  long  remain  in  this  condition. 
In  the  course  generally  of  a  few  hours,  or  at  the  utmost  of  a  day, 
the  symptoms  mitigate,  or  yield  entirely  to  treatment ;  and,  pale 
and  visibly  emaciated  though  he  be,  he  speedily  regains  his  pre- 
vious health.  Only  in  some  cases  the  disease  proves  intractable, 
and,  after  running  on  for  several  days,  passes  into  a  state  of  hope- 
less collapse. 

There  are  not  many  morbid  states  with  which  cholera  morbus 
is  likely  to  be  confounded.  It  may  be  mistaken,  as  we  shall  pres- 
ently see,  for  epidemic  cholera.  We  find  many  points  of  similarity 
between  it  and  irritant  poisoning,  and  some  between  it  and  acute 
gastritis.  But  there  are  also  strong  points  of  difference.  The 
vomiting  and  purging  produced  by  an  irritant  poison  do  not 
come  on  at  the  same  time ;  the  vomiting  precedes  the  purging. 
The  pain  is  first  in  the  epigastrium,  thence  it  may  spread.  More- 
over, we  often  detect  signs  in  the  mouth  or  fauces  which  prove  the 
irritating  character  of  the  substance  swallowed.     The  vomiting  of 


544  MEDICAL    DIAGNOSIS. 

acute  gastritis  is  accompanied  by  a  hot  skin,  and  a  small,  tense 
pulse ;  whereas  the  skin  of  cholera  morbus  patients  is  commonly 
cool,  and  the  pulse  very  compressible  and  feeble. 

Cholera. — The  formidable  complaint  known  as  epidemic  chol- 
era, Asiatic  cholera,  malignant  cholera,  or  by  the  simple  name  of 
cholera,  has  some  striking  features  of  resemblance  to  the  disorder 
just  considered.  It  shares  with  cholera  morbus  the  vomiting  and 
purging,  the  cramps,  the  sudden  depression;  but  it  is  an  affection 
of  different  origin  and  of  much  more  serious  import,  and  presents 
symptoms  not  encountered  in  the  cholera  that  occurs  yearly  during 
the  hot  weather.  And,  although  I  am  describing  it,  on  account  of 
the  gastric  and  intestinal  disturbances  which  form  so  prominent  a 
part  of  its  manifestations,  in  the  same  group  with  cholera  morbus 
and  among  the  disorders  of  the  alimentary  tube,  I  am  doing  so  for 
the  sake  of  clinical  convenience,. and  contrary  to  sound  pathology; 
for  cholera  is  not  an  affection  either  of  the  stomach  or  of  the  intes- 
tines ;  it  is  an  epidemic  constitutional  disorder  of  the  most  formi- 
dable character,  generated  by  a  poison  transmitted  to  us  from  the 
East.  The  poison  leads  to  a  easting  off  of  the  epithelium  of  the 
mucous  membrane  of  the  alimentary  tube  ;  perhaps  to  changes  in 
the  membrane.  But  the  engorged  veins  all  over  the  body ;  the 
ready  exosmose  of  the  watery  parts  of  the  blood ;  the  frightfully 
rapid  prostration  ;  the  sudden  blight  which  befalls  the  nervous 
powers, — are  elements  even  more  characteristic,  and  which  throw 
more  light  on  the  nature  of  the  fearful  malady,  than  the  compara- 
tively uncertain  and  far  from  uniform  appearances  of  irritation  in 
the  intestinal  canal. 

The  access  of  cholera  is  at  times  sudden  and  most  unexpected ; 
the  patient,  previously  in  good  health,  is  stricken  down  without 
warning  by  the  force  of  the  poison.  More  generally  there  is  a 
premonitory  stage :  a  stage  of  languor,  low  spirits,  uneasiness, 
headache,  and  diarrhoea.  The  effects  of  the  tainting  of  the  at- 
mosphere with  the  morbific  matter  are  indeed  visible  in  hun- 
dreds of  individuals  who,  during  the  prevalence  of  cholera,  suffer 
from  these  premonitory  symptoms  without  any  of  greater  danger 
arising,  ^ay,  the  same  influences  which  give  rise  to  a  choleraic 
diarrhoea  in  healthy  persons  have  the  effect  of  rendering  the 
bowels  of  those  habitually  constipated  regular,  and  sometimes 
even  loose. 


DISEASES    OF    THE    INTESTINES    AND    PERITONEUM.        545 

When  the  malignant  disease  is  fairly  developed,  there  is  vomit- 
ing as  well  as  purging.  The  contents  of  the  stomach  and  intes- 
tines are  first  voided,  and  then  large  quantities  of  a  rather  turbid 
fluid  resembling  rice-water,  with  whitish  particles  like  rice  float- 
ing in  it.  They  are  the  epithelial  cells  of  the  alimentary  tube, 
which  have  been  thrown  off  from  the  mucous  membrane.  Simul- 
taneously with  the  vomiting  and  purging,  or  very  shortly  after, 
come  on  severe  spasmodic  pains  in  the  abdomen  and  cramps  of 
the  muscles  of  the  belly  and  of  the  extremities.  With  all  this  there 
are  a  burning  sensation  in  the  epigastric  region;  an  unquenchable 
desire  for  cold  drinks;  a  cool  skin;  a  pulse  slightly  more  frequent 
than  normal ;  a  hurried  and  oppressed  breathing;  and  a  rapidly 
progressing  exhaustion.  The  case  now  stands  on  the  very  verge 
of  collapse.  Should  this  succeed, — and  unfortunately  it  does  suc- 
ceed in  a  fearfully  large  number  of  instances, — a  state  of  things 
is  witnessed  which,  once  seen,  remains  indelibly  engraved  on  the 
memory.  The  pulse  is  quick,  but  hardly  perceptible.  The  dis- 
charges cease,  and  so  do  often  the  cramps.  The  skin  is  cold, 
covered  with  a  clammy  sweat,  and  has  a  bluish  look.  The  nails 
and  the  lips  have  the  same  unnatural  appearance.  The  whole  body 
shrinks,  and  seems  at  times  almost  to  wither  visibly  even  while  under 
inspection.  The  countenance  assumes  the  aspect  of  death  ;  the  eyes 
are  sunken  and  have  a  glassy  look.  The  intellect  is  commonly 
clear;  but  when  the  patient  talks,  the  words  fall  strangely  on  the 
ear.  It  seems  as  if  a  corpse  had  spoken,  and  the  voice  is  husky 
and  faint.  The  tongue  and  the  expired  air  are  cold.  No  symp- 
tom, indeed,  has  struck  me  more  forcibly  than  the  icy  breath. 

But  the  symptoms  do  not  always  take  place  in  the  order  de- 
scribed, nor  are  they  all  uniformly  present.  The  vomiting  and 
purging  may  be  wanting  from  the  onset,  and  so  too  may  the 
cramps.  Only  one  symptom  is  never  absent, — the  tendency  to 
early  sinking.  Sometimes  a  stage  of  perfect  collapse  is  reached 
with  frightful  rapidity:  instead,  as  is  commonly  the  case,  of  several 
hours  elapsing  before  complete  prostration  comes  on,  the  vital 
powers  are  at  once  laid  low  by  the  assault  of  the  dreadful  malady. 
When  cholera  prevailed  in  Philadelphia  some  years  since,  I 
attended  a  woman  who  at  six  o'clock  in  the  morning  was  in  per- 
fect health  and  who  in  a  little  more  than  half  an  hour  afterward 
was  lifeless.     There  was  neither  vomiting  nor  purging ;  nothing 

35 


54:6  MEDICAL    DIAGNOSIS. 

but  cramps,  stupor,  and  speedy" collapse.  Such  cases  are  not  un- 
common in  the  home  of  cholera, — India.  Post-mortem  inspection 
shows  the  thin  rice-water  fluid  locked  up  in  the  alimentary  canal. 
Nature  may  have  made  an  effort  to  eliminate  the  poison;  but 
before  she  completes  her  task,  life  is  palsied. 

In  those  cases  that  recover,  the  vomiting  and  purging  gradually 
subside,  the  skin  becomes  warm,  the  pulse  fuller,  the  urine — 
which,  while  the  disease  was  at  its  height,  was  not  passed,  perhaps 
not  secreted — is  again  voided,  the  patient  falls  into  a  refreshing 
sleep,  and,  the  symptom  most  favorable  of  all,  bile  reappears  in 
the  stools.  Even  in  apparently  hopeless  cases  of  collapse  we  may 
be  fortunate  enough  to  witness  these  favorable  changes.  But 
where  the  prostration  has  been  great,  the  reaction  is  apt  to  be 
violent.  A  decided  fever  of  low  type,  with  rapid  pulse  and  heat 
of  skin,  and  attended  very  often  by  alarming  cerebral  symptoms, 
succeeds;  and  the  urinary  secretion,  even  if  it  have  been  restored, 
becomes  again  very  scanty.  Thus  the  period  of  reaction  brings 
with  it  new  dangers,  and  of  a  kind  which  are  sometimes  insur- 
mountable. And  this  low  form  of  fever,  very  similar  to  typhoid, 
though  readily  enough  distinguished  by  the  preceding  symptoms, 
may  last  for  upwards  of  a  week  before  death  takes  place  or  the 
signs  of  danger  gradually  yield.  Now,  this  cholera  typhoid  may 
be  preceded  by  scanty  urine  and  marked  uraemia,  but  it  may  also 
■exist  independently  of  this  morbid  state,  though  probably  equally 
due  to  the  blood  being  loaded  with  broken-down  material.  In 
cases  in  which  uraemia  sets  in,  whether  it  be  followed  or  not 
by  a  fever  of  low  type,  there  is  at  first  but  little,  if  any,  heat  of 
skin,  and  a  slow  pulse;  the  patient  is  wild,  restless,  or  drowsy; 
.the  kidneys  act  very  imperfectly,  the  urine  is  greatly  deficient 
in  urea,  and  usually  contains  albumen.  These  are  very  danger- 
ous eases,  and  if  the  secretion  be  seriously  retarded  for  more  than 
twenty-four  hours  they  are  likely  to  perish. 

In  any  case  of  cholera,  convalescence  is  apt  to  be  slow.  For 
weeks  or  months  irritability  of  the  intestinal  canal  remains;  and 
I  have  met  with  instances  in  which  it  has  never  disappeared. 

It  would  be  needless  to  go  into  any  minute  description  of  the 
differences  between  cholera  and  other  affections :  its  features  are 
not  to  be  mistaken.  Cholera  morbus  is  the  only  disorder  which 
really  resembles  it.     The  dividing-line  is  drawn  by  the  absence 


DISEASES    OF    THE    LIVER.  547 

of  bile  in  the  discharges,  the  rice-water  evacuations,  the  greater 
severity  and  more  rapid  progress  of  the  symptoms,  the  bluish 
color  of  the  surface  in  the  stage  of  collapse,  and  the  epidemic 
character  of  the  more  fatal  disease.  In  the  truly  epidemic  nature 
of  the  distemper,  and  in  the  speedy  collapse,  which  shows  but 
too  plainly  that  some  highly  deleterious  matter  has  poisoned  the 
system,  lie,  even  in  doubtful  cases,  the  proofs  that  we  are  dealing 
with  malignant  cholera ;  for  sometimes  rice-water  discharges  occur 
in  bad  cases  of  cholera  morbus;  occasionally,  too,  this  disorder 
appears  to  be  epidemic ;  but  it  is  so  only  on  a  very  small  scale. 
To  speak  more  accurately,  it  is  an  endemic  on  a  large  scale.  We 
find  no  proofs  of  a  virulent  poison  wafted  about  in  the  atmos- 
phere, or  directly  conveyed  by  human  intercourse  and  traffic,  and 
so  noxious  as  to  smite  animals  as  well  as  man.  Certain  rare  cases 
of  irritant  poisoning,  especially  from  arsenic,  bear  some  resem- 
blance to  cholera,  although  generally  more  to  cholera  morbus. 
The  severe  vomiting  in  advance  of  the  purging,  the  usual  absence 
of  rice-water  stools,  the  presence  of  bloody  evacuations,  and  the 
traces  left  by  the  poison  in  the  mouth,  furnish  significant  features 
of  distinction. 

The  mortality  of  cholera  is  very  various.  In  many  epidemics 
one-half,  or  more  than  one- half,  die.  In  some  the  havoc  is  far 
less.  The  first  cases  that  occur  almost  invariably  perish ;  and, 
taken  altogether,  the  malady  ranks  among  the  most  destructive 
to  life.  Its  epidemic  visitations  are  what  the  plague  was  to  the 
Europeans  of  the  seventeenth  century,  and  what  yellow  fever  still 
is  to  the  inhabitants  of  this  continent.  It  is  at  least  as  dangerous; 
its  nature  is  as  hidden ;  its  management  is  as  unsatisfactory. 


SECTION  III. 

DISEASES   OF   THE   LIVER. 

We  have  already  inquired  into  the  clinical  methods  of  exam- 
ining the  liver  so  as  to  form  a  judgment  of  its  physical  character- 
istics. Let.  us  now  look  at  some  of  the  symptoms  which  a  disease 
of  this  viscus  generally  manifests. 


548  MEDICAL    DIAGNOSIS. 

Pain  is  one  of  these.  It  is  generally  dull,  and  radiates  from 
the  seat  of  the  liver  to  the  upper  portion  of  the  thorax,  to  the 
scapula,  to  the  shoulder,  and  to  the  umbilicus.  Commonly  it  is 
persistent  and  increased  by  strong  pressure;  yet  the  exceptional 
cases  are  very  numerous. 

Digestive  troubles  are  usual  accompaniments  of  hepatic  affec- 
tions. They  are  of  all  grades,  from  mere  indigestion  to  the  signs 
announcing  chronic  gastritis. 

Disturbance  of  the  portal  circulation  is  another  frequent  conse- 
quence of  disease  of  the  liver.  The  flow  of  blood  is  interfered 
with,  and  the  result  is  seen  in  the  occurrence  of  dropsy,  of  piles, 
of  partial  peritoneal  inflammation,  of  hemorrhages  from  the  en- 
gorged stomach  and  intestines,  and  of  enlargement  of  the  spleen 
and  of  the  veins  on  the  surface  of  the  abdomen. 

Jaundice. — But  the  most  significant  manifestation  of  hepatic 
disorder  is  jaundice.  This  marked  sign  shows  itself  by  the  yellow 
tinge  imparted  to  the  skin  and  to  the  conjunctiva.  Yet  the  yel- 
lowness is  not  confined  to  these  structures :  it  may  often  be  found 
in  internal  organs.  Besides  the  peculiar  aspect  of  the  surface, 
icterus  is  usually  attended  with  depression  of  the  circulation  ;  with 
itching  of  the  skin ;  with  high-colored  urine,  in  which  the  main 
ingredients  of  bile  can  be  detected,  and  sometimes  small  quan- 
tities of  albumen,  or  hyaline  and  epithelial  casts  without  albumen; 
with  constipation,  the  fseces  passed  being  hard  and  knotty,  and 
often  of  bad  odor,  and  almost  devoid  of  color,  or  sometimes  of  a 
leaden  hue. 

Jaundice,  there  can  be  no  doubt,  is  due  to  the  presence  of  biliary 
constituents  in  the  blood ;  but  as  yet  it  is  not  satisfactorily  solved 
how  they  get  there.  It  was  the  opinion  of  Haller  and  of  Boer- 
haave,  and  it  is  still  the  opinion  of  many,  that  the  bile,  in  conse- 
quence of  some  impediment  to  its  outward  passage,  is  reabsorbed 
and  conveyed  into  the  circulation.  Others  hold  that  the  liver  is 
at  fault  by  not  performing  its  function  and  clearing  the  blood  of 
the  ingredients  which  form  the  bile ;  these,  whether  they  be  bile- 
pigment,  or  the  biliary  acids,  or  cholesterin,*  accumulate  in  the 
blood  and  give  rise  to  the  characteristic  discoloration  of  jaundice. 
Xow,  neither  of  these  theories  will  explain  all  cases :  many  in- 

*  Austin  Flint.  Jr.,  American  Journal  of  the  Medical  Sciences,  Oct.  1862. 


DISEASES    OF    THE    LIVER.  549 

stances  of  jaundice  are  at  once  interpreted  by  the  former  suppo- 
sition, but  in  others  it  does  not  suffice,  and  the  view  of  jaundice 
from  suppression  appears  more  probable.  Still  other  theories  have 
been  advanced  to  account  for  some  obscure  forms  of  jaundice ; 
such  as  the  view  of  Frerichs,  that  the  metamorphosis  of  the 
colorless  bile-acids  which  enter  the  blood  and  are  there  changed 
into  urinary  pigment  is  arrested  by  the  action  of  some  poison, 
and  that  the  acids  are  converted  into  bile-pigment,  which,  circu- 
lating with  the  blood,  changes  the  hue  of  the  surface  and  of  the 
secretions. 

The  diagnosis  of  jaundice  is  easy.  The  only  morbid  states  with 
which  it  is  liable  to  be  confounded  are  the  slightly  yellowish  hue 
of  chlorosis,  or  of  some  cachectic  conditions  associated  with  organic 
visceral  disease,  and  the  yellow  appearance  of  the  conjunctiva 
which  is  natural  to  some  persons.  The  changed  color  of  the 
countenance  due  to  chlorosis  is  discriminated  by  its  association 
with  a  bluish-white  or  pearly-tinted  eye,  and  with  pale  lips  and 
tongue  and  transparent  ear.  The  absence  of  a  yellow  tint  from 
the  conjunctiva  is  of  equal  importance  in  discriminating  from 
jaundice  the  yellowish  hue  of  cancer,  of  malaria,  of  lead-poison- 
ing, and  of  granular  kidneys.  Of  course  the  history  of  the  case 
and  the  attending  symptoms  also  aid  us.  The  yellow  look  of  the 
eye  sometimes  found  in  health,  and  at  times  dependent  on  sub- 
conjunctival fat,  is  known  by  the  unequal  distribution  of  the  color 
and  by  the  absence  of  a  yellow  hue  of  the  complexion.  But  in 
negroes,  and  it  is  in  them  especially  that  we  meet  with  the  dis- 
colored conjunctiva,  we  have  to  judge  by  the  character  of  the 
coloration  alone.  In  any  doubtful  case,  the  easy  chemical  tests 
by  which  we  detect  bile-pigment  in  the  urine  will  solve  the  doubt. 

When  once  jaundice  has  been  recognized,  the  difficulty  in  diag- 
nosis may  be  said  to  begin.  Of  the  many  distinct  sources  of  icterus, 
which  one  is  before  us?  Now,  clinically  speaking,  the  causes  may 
be  thus  grouped:  1.  Diseases  of  the  liver.  2.  Diseases  of  the 
bile-ducts.  3.  Diseases  of  parts  remote  from  the  liver,  or  general 
diseases  leading  to  a  disorder  of  the  viscus.  4.  Certain  poisons 
acting  upon  the  blood.  In  the  first  two  of  these  causes  there  is, 
as  it  were,  a  mechanical  difficulty  impeding  or  arresting  the  ex- 
cretion of  bile;  in  the  third  and  fourth,  no  obvious  impediment 
exists,  and  the  origin  of  the  jaundice  is  usually  obscure.     Cases 


550  MEDICAL    DIAGNOSIS. 

belonging  to  the  third  group,  however,  may  be  at  times  explained 
on  the  supposition  of  a  derangement  of  the  hepatic  circulation. 
Let  us  look  at  some  of  the  peculiarities  of  these  groups. 

1.  The  jaundice  connected  with  diseases  of  the  liver  is,  as  a 
rule,  recognized  by  its  association  with  changed  dimensions  of 
the  organ,  and  with  pain  or  other  palpable  signs  referred  to  the 
hepatic  region.  It  is  met  with  in  all  disorders  of  the  liver,  but 
does  not  exist  in  all  in  the  same  degree  of  intensity.  It  reaches  a 
high  development  and  is  combined  witli  cephalic  symptoms  in 
acute  yellow  atrophy.  In  fatty  liver,  in  waxy  liver,  in  cancer,  in 
cirrhosis,  and  in  acute  hepatitis  it  is  not  very  marked,  and  may 
be,  indeed,  absent:  in  truth,  it  can  hardly  be  looked  upon  as 
belonging  to  the  first-mentioned  morbid  states. 

2.  Jaundice  arising  from  disease  of  the  larger  biliary  ducts,  such 
as  their  catarrhal  swelling;  or  in  consequence  of  their  obstruction 
by  pressure  exercised  by  a  morbid  enlargement  of  adjacent  parts, 
as  of  the  pyloric  extremity  of  the  stomach  or  the  pancreas;  or  by 
tumors,  aneurismal,  cancerous,  or  faecal,  closing  the  orifice  of  the 
duct ;  or  by  the  stoppage  of  the  ducts  by  inspissated  bile  or  a  biliary 
calculus,  or  by  hydatids  or  foreign  bodies  from  the  intestines, — is 
a  form  of  the  malady  in  which  the  icterus  is  commonly  intense.  It 
occasions  no  head  symptoms ;  and  when  these  are  absent  in  a  case 
of  very  deep  jaundice,  when,  further,  the  stools  are  completely  dis- 
colored, we  are  generally  correct  in  attributing  the  morbid  phenom- 
ena to  an  impediment  to  the  flow  of  bile  through  the  common 
bile-duct  or  the  hepatic  duct.  If  this  impediment  be  due  to  the 
impaction  of  a  gall-stone,  severe  colicky  pains  are  encountered  in 
addition  to  the  signs  just  mentioned. 

Harley's  statement*  that  in  the  jaundice  due  to  reabsorption — 
precisely  the  form  of  jaundice,  therefore,  that  happens  if  any 
serious  obstacle  in  the  biliary  passages  exist — the  biliary  acids 
which  have  been  formed  in  the  liver  pass  into  the  blood,  and 
thence  into  the  urine,  and  that  this  does  not  occur  if  the  jaundice 
be  due  to  suppression,  has  not  been  borne  out  by  other  observers. 
Nor  has  the  modification  of  Pettenkofer's  test,  by  which  the  biliary 
acids  are  detected,  been  accepted  as  available. 

3.  Illustrations  of  jaundice  following  some  local  lesion  of  other 

*  Jaundice,  its  Pathology  and  Treatment,  London,  1863. 


DISEASES    OF    THE    LIVER.  551 

parts  of  the  body,  or  appearing  in  the  course  of  a  general  consti- 
tutional affection,  are  furnished  by  the  jaundice  which  happens  in 
some  cases  of  pneumonia,  or  which  is  encountered  in  remittent,  in 
typhus,  in  relapsing,  or  in  yellow  fever.  In  these  fevers  the 
vellow  hue  is  generally  found  to  be  connected  with  an  acute 
enlargement  and  with  structural  changes  in  the  organ ;  and  in  the 
latter  malady,  with  disordered  hepatic  circulation  and  a  fatty 
degeneration  of  the  secreting-cells. 

To  recognize  the  form  of  jaundice  under  discussion,  we  must 
examine  all  the  viscera  of  the  body  with  care,  laying  stress  upon 
the  history  of  the  case  and  the  phenomena  attending  the  jaundice. 
Otherwise,  too  much  importance  will  be  attached  to  this  symptom, 
and  the  disturbance  of  the  liver  regarded  as  forming;  the  whole 
complaint,  when  it  is  but  a  small  part  of  it. 

4.  Poisons  acting  upon  the  blood  sometimes  give  rise  to  jaundice 
very  rapidly ;  for  instance,  the  jaundice  from  snake-bites  or  from 
pytemie  affection  is  apt  to  be  suddenly  developed  and  to  become 
quickly  intense.  In  the  history  of  the  accident  and  the  signs  of 
alteration  of  the  blood,  we  possess  the  means  of  distinguishing 
this  form  of  jaundice.  Certain  mineral  poisons,  such  as  phospho- 
rus, copper,  antimony,  come  into  the  same  category.  Chloroform 
and  ether,  too,  may  lead  to  abnormal  blood  changes  producing 
jaundice. 

Thus,  then,  we  can  bring,  clinically  speaking,  most  of  the 
varieties  of  jaundice  under  one  or  the  other  of  the  four  heads 
mentioned;  and,  roughly  speaking,  they  come  really  under  two, — 
obstructive  jaundice,  where  the  disorder  results  from  obstruction 
of  the  common  duct,  and  jaundice  without  such  obstruction.  But 
there  are  a  few  kinds  of  jaundice  which  it  is  far  from  easy  to 
classify  with  precision :  one  of  these  is  the  jaundice  from  mental 
emotion  ;  the  other,  the  jaundice  of  newly-born  children. 

As  regards  the  former,  it  is  difficult  to  explain  its  cause;  nor, 
indeed,  has  any  satisfactory  explanation  been  given.  All  we  know 
is,  that  violent  anger  or  fright  may  lead,  within  a  very  brief  space 
of  time,  to  the  development  of  jaundice,  and  that  the  quickly- 
occurring  discoloration  is  not  dangerous,  or  of  long  duration. 
The  perverted  innervation  caused  by  concussion  of  the  brain 
leads  to  a  similar  kind  of  jaundice. 

The  iaundice  of  newlv-born  children — icterus  neonatorum — is 


552 


MEDICAL    DIAGNOSIS. 


ordinarily  a  mild  complaint,  which  appears  soon  after  birth, 
and  rarely  lasts  over  two  weeks.  The  yellow  hue  of  the  skin 
is  often  very  deep;  yet  the  child  does  not  suffer,  and  has  no 
febrile  excitement.  The  bowels  are  constipated,  but  the  stools 
are  not  necessarily  altered  in  their  color;  nor  do  they  usually 
present  the  clayey  look  which  might  be  expected  from  the  aspect 
of  the  skin  and  of  the  conjunctiva.  The  origin  of  the  jaundice 
is  obscure.  It  was  attributed  by  Frank  to  a  stoppage  of  the 
choledoch  duct  by  meconium.  Recent  writers,  and  prominently 
Epstein,*  look  upon  it  as  of  blood  origin,  as  pysemic.  West 
states  that  it  is  most  frequently  observed  in  children  prema- 
turely born. 

The  prognosis  of  jaundice  depends  upon  its  cause.  In  general 
terms,  we  may  say  that  if  the  icterus  last  upwards  of  two  months 
it  is  always  a  matter  of  some  danger,  as  showing,  in  all  likelihood, 
an  organic  lesion  of  the  liver  or  of  the  biliary  passages.  If  the 
discoloration  of  the  skin  be  attended  with  cerebral  symptoms,  the 
patient's  state  is  precarious.  Icterus  accompanying  affections  of 
the  blood,  peritonitis,  or  pneumonia  is  an  unfavorable  sign ;  so 
is  a  very  dark  color  of  the  skin.  Indeed,  cases  of  "green"  or 
"  black"  jaundice  generally  prove  fatal. 

Before  examining  the  hepatic  maladies  according  to  their  clinical 
features,  let  us  look  at  their  pathological  classification  : 

Diseases  of  the  Liver. 


Diseases  of 
hepatic 
parenchy- 
ma. 


Hypersemia / 


Inflammation  and  its  conse- 
quences  


Atrophy. 


Hypertrophy. 


Acute  congestion. 
Chronic  congestion. 
Acute  hepatitis. 
Chronic  hepatitis. 
Interstitial       inflammation; 

cirrhosis. 
Abscess. 
Softening. 
Syphilitic  hepatitis. 
Acute  or  yellow  atrophy. 
Simple  chronic  atrophy. 
Bed  atrophy. 
Partial. 
General. 


*  Sammlung  Klinischer  Vortrage,  No.  180,  1880. 


DISEASES    OF    THE    LIVER. 


553 


Diseases  of  the  Liver. — Continued. 


Diseases  of 
hepatic 
parenchy-  . 
ma, — Con 
tinned. 


Degeneration  and  new  for- 
mations   


Diseases   of 
biliary 

passages. 


Diseases  of 
blood-ves- 
sels. 


Inflammation  of  gall-bladder 
and  gall-ducts 

Occlusion  of  biliary  pas- 
sages. 

Dilatation  of  gall-bladder. 

Morbid  growths. 

Foreign  bodies;  concretions, 
such  as  eiall-stones. 


Of  hepatic  artery. 
Of  hepatic  vein. 
Of  portal  vein 


Fatty  liver. 
Waxy  liver. 
Pigment  liver. 
Cancer. 
Sarcoma. 

Lymphatic  growths. 
Gummata. 
Tubercle. 
Hydatids. 
Simple  cysts. 

Catarrhal. 

Exudative. 

Suppurative. 


Inflammation. 
Aneurism. 

Suppurative  inflammation. 
Coagulation  of  blood. 


Acute  Diseases  of  the  Liver  attended  generally  with  Slight 
Enlargement  of  the  Organ,  and  with  more  or  less,  though 
rarely  very  much,  Jaundice. 

Acute  Congestion. — This  arises  from  organic  disease  of  the 
heart,  from  obstructed  portal  circulation,  from  irritating  food  and 
drink  and  disturbed  digestion,  or  from  malarial  poison ;  sometimes 
it  is  caused  by  a  high  temperature,  by  a  blow  on  the  hepatic 
region,  by  arrest  of  the  menstrual  flow,  by  a  protracted  chill,  or 
by  violent  exercise.  The  acute  congestion  is  characterized  by  pain 
in  the  right  shoulder  and  loin,  by  an  unpleasant  sensation  of  weight 
and  of  tension  in  the  right  hypochondrium,  increased  after  meals, 
and  by  nausea  and  vomiting.  At  the  same  time  the  action  of  the 
bowels  is  deranged,  being  generally  too  frequent;  the  tongue  is 
coated ;  there  is  flatulency,  as  well  as  depression  of  spirits,  with 
loss  of  appetite  and  of  strength ;  and  the  liver  is  enlarged.  But 
we  find  ordinarily  only  slight  jaundice,  and  no  fever.  Gradually 
these  signs  disappear;   the  increased  hepatic  dulness,  however, 


554  MEDICAL    DIAGNOSIS. 

remaining  for  some  time  after  the  gastric  and  intestinal  disturb- 
ances have  abated.  Not  (infrequently  the  acute  disorder  passes 
by  imperceptible  degrees  into  a  chronic  state. 

Acute  Hepatitis. — The  symptoms  of  this  affection  are  much 
the  same  as  those  of  acute  congestion,  except  that  we  observe 
more  thirst,  greater  gastric  irritability,  a  more  embarrassed  respi- 
ration, heat  of  surface  with  rise  of  general  temperature,  dry  cough, 
and  in  some  cases  an  accelerated  pulse,  enlargement  of  the  spleen, 
and  albumen  in  the  urine.  The  pain  is  dull,  and  associated  with 
a  feeling  of  tension  in  the  hypochondrium.  It  is  increased  on 
pressure,  yet  not  much  so,  unless  the  peritoneal  covering  of  the 
liver  be  involved.  Jaundice  is  not  generally  marked;  indeed,  at 
the  beginning  of  the  disease  it  is  often  absent.  Ascites,  vomiting 
of  blood,  and  brown  spots  on  the  skin  have  been  noticed.* 

Acute  hepatitis  is  common  in  hot  countries,  and  many  of  the 
cases  are  connected  with  dysentery.  It  may  end  in  resolution ; 
but  the  inflammation,  especially  in  persons  of  indolent  or  intem- 
perate habits,  often  terminates  in  suppuration,  and  pus  collects  in 
the  substance  of  the  liver.  The  occurrence  of  this,  the  tropical 
abscess,  as  Murchisonf  calls  it,  is  indicated  by  recurring  rigors,  by 
fever  of  a  remittent  type,  by  clammy  perspirations,  by  prostration 
and  loss  of  flesh.  Not  unfrequently,  too,  a  decided  fulness  of  the 
side  may  be  noticed,  and  occasionally  careful  palpation  detects 
deep-seated  fluctuation.  After  an  abscess  has  formed,  the  danger 
is  great;  secondary  abscess  may  follow,  and  the  patient  is  apt  to 
perish  from  peritonitis,  from  blood-poisoning,  or  from  the  uncon- 
trollable vomiting,  delirium,  singultus,  and  meteorism.  Yet  re- 
covery may  take  place.  The  matter  may  be  discharged  through 
the  abdominal  walls,  or  burst  into  the  intestine,  or  find  its  way 
through  the  diaphragm  into  the  pleural  cavity,  to  be  discharged 
through  the  lung.  But  as  the  phenomena  of  abscess  of  the  liver 
following  acute  inflammation,  if  we  except  jaundice,  which  is  a 
rare  symptom,  and  the  usually  much  longer  duration  of  the  case, 
are  the  same  as  when  the  collection  of  pus  is  consequent  upon 
other  morbid  states,  we  shall  not  here  indicate  what  we  shall  pres- 
ently more  fully  consider. 


*  Jos.  Brown,  Phila.  Med.  and  Surg.  Keporter,  June,  1873. 
|  Diseases  of  the  Liver,  2d  edit.,  1877. 


DISEASES   OF    THE    LIVER.  555 

Let  us  now  examine  the  maladies  with  which  acute  inflam- 
mation of  the  liver  may  be  confounded,  premising  that,  making 
allowance  for  the  febrile  phenomena  and  the  other  slight  signs  of 
difference  just  indicated  between  hepatic  inflammation  and  hepatic 
congestion,  the  same  remarks  will  apply  to  the  distinction  between 
this  morbid  condition  and  the  affections  about  to  be  mentioned. 
The  complaints  resembling  acute  hepatitis  are  : 

Perihepatitis  ; 

Inflammation  of  the  Portal  Veins; 

Pigment  Liver; 

Chronic  Hepatic  Diseases  with  Acute  Symptoms; 

Acute  Non-hepatic  Diseases  with  Jaundice; 

Diaphragmatic  Pleurisy  ; 

Inflammation  of  the  Biliary  Passages; 

Acute  Yellow  Atrophy. 

Perihepatitis. — Inflammation  of  the  serous  covering  of  the  liver, 
limited  to  this  covering,  or  spreading  perhaps  here  and  there  to 
the  most  superficial  portions  of  the  structure  of  the  gland,  is  not 
a  frequent  disease.  Unless  it  be  of  syphilitic  origin,  it  is  scarcely 
ever  a  primary  affection ;  it  is  generally  caused  by  the  extension 
of  inflammation  from  organs  adjacent  to  the  liver, — as  from  the 
stomach,  intestines,  diaphragm,  or  pleura, — and  may  therefore 
be  looked  upon  as  a  local  peritonitis ;  or  it  is  an  attendant  upon 
disease  of  the  liver  itself.  In  the  latter  case  it  presents  no  pe- 
culiar symptoms,  except  that  it  adds  tenderness  to  the  signs  of 
the  hepatic  malady  it  complicates.  Under  other  circumstances  it 
is  more  likely  to  be  confounded  with  acute  inflammation  of  the 
liver-texture.  Yet  the  far  greater  tenderness,  the  severe  pain  upon 
motion  or  deep  inspiration  and  its  marked  increase  when  the  pa- 
tient lies  on  either  side,  occasionally  a  grating  friction  sound,  the 
perfectly  normal  size  of  the  gland,  the  history  of  the  case  or  evi- 
dences of  a  disease  in  the  neighborhood  of  the  liver  that  is  likely 
to  have  caused  the  malady,  the  absence  of  jaundice,  and  the  slight 
fever,  distinguish  the  perihepatic  inflammation  from  true  hepatitis. 

Inflammation  of  the  Portal  Veins. — An  inflammation  of  the 
portal  veins,  terminating  in  suppuration,  is  very  liable  to  be  mis- 
taken for  acute  inflammation  of  the  liver.  Nor  are  there,  in  truth, 
any  positive  symptoms  by  which  we  can  discriminate  between  the 
two  maladies.     Still,  we  may  sometimes  suspect  that  the  veins  are 


556  MEDICAL    DIAGNOSIS. 

the  seat  of  inflammation,  rather  than  the  structure  of  the  liver,  if, 
with  the  signs  of  acute  and  painful  enlargement  of  the  organ,  we 
find  jaundice,  thin  and  copious  stools,  recurring  chills  and  profuse 
sweats,  emaciation,  increase  in  size  of  the  spleen,  without  any  ap- 
parent fluctuation  or  other  signs  of  an  hepatic  abscess ;  if  there 
exist  pains  between  the  ensiform  cartilage  and  the  umbilicus,  or 
in  the  epigastrium  or  right  hypochondrium,  or  shooting  to  the 
lumbar  and  sacral  regions;  if  following  these  symptoms  appear 
swelling  of  the  veins  of  the  abdominal  walls,  and  striking  evi- 
dences  of  hectic  fever,  or  of  peritonitis ;  and  if  these  phenomena 
be  encountered  in  a  person  who,  on  account  of  a  previous  affection 
of  the  intestines  or  spleen,  or  of  any  other  organ  having  a  direct 
venous  connection  with  the  portal  circulation,  is  liable  to  disease 
of  the  portal  system.  Marked  enlargement  of  the  spleen  is  a 
constant  feature  of  impediment  in  the  portal  vein,  whether  from 
inflammation  or  from  thrombosis. 

Pigment  Liver. — "  In  individuals  who  die  from  the  effects  of 
marsh  poison,  under  symptoms  of  severe  intermittent,  remittent, 
or  continued  fevers,  we  frequently  find  peculiar  changes  of  the 
liver  associated  with  functional  derangements  of  the  organ,  and 
of  the  parts  pertaining  to  the  portal  system.  The  liver  presents 
a  steel-gray,  or  blackish,  or  not  unfrequently  a  chocolate  color ; 
brown  insulated  figures  are  observed  upon  a  dark  ground.  This 
change  of  color  is  produced  by  pigment-matter  which  is  accumu- 
lated in  the  vascular  apparatus  of  the  gland."  So  says  Frerichs, 
the  observer  who  has  most  carefully  described  the  pigment  liver.* 

But  the  liver  is  not  the  only  organ  implicated  in  the  morbid 
process :  the  spleen  is  commonly  affected ;  the  blood  becomes 
watery,  its  corpuscles  are  broken  down,  and  it  contains  large 
quantities  of  pigment ;  and  pigment  accumulates  in  the  kidneys 
or  in  the  brain.  Xow,  the  effect  of  all  this  is  to  occasion  marked 
symptoms,  besides  those  referable  to  the  derangement  of  the  liver; 
for  it  is  not  unusual  to  find  grave  cerebral  disturbance,  albuminuria, 
hemorrhage  from  the  intestines,  profuse  diarrhoea,  and  enlargement 
of  the  spleen.  Irrespective  of  these  manifestations,  we  must  note 
the  singular  ash  or  grayish-yellow  color  of  the  skin,  the  evident 
hydrsemia,  and  the  great  amount  of  pigment  which  is  readily  de- 

*  Treatise  on  Diseases  of  the  Liver,  vol.  i. 


DISEASES   OF    THE    LIVER.  557 

tected  in  even  a  few  drops  of  the  blood.  The  fever  that  accom- 
panies the  morbid  condition  is  of  an  intermittent  type ;  the  pulse 
is  not,  as  a  rule,  much  accelerated,  and  the  jaundice  is  generally 
slight.  In  India,  pigmentary  degeneration  of  the  liver  tends  to 
suppurative  hepatitis.* 

When  we  contrast  the  phenomena  described  with  those  of  acute 
hepatitis,  we  see  at  once  the  difference.  The  fever,  the  aspect  of 
the  patient,  the  blood  full  of  dark  pigment,  and  the  frequency  of 
cerebral  symptoms  are  entirely  unlike. 

Chronic  Hepatic  Disease  with  Acute  Symptoms. — We  occasion- 
ally meet  with  patients  who  seem  to  be  laboring  under  an  acute 
affection  of  the  liver,  either  some  form  of  inflammation  of  the 
liver-structure  or  of  the  biliary  passages,  or  under  congestion  of 
the  liver,  but  in  whom  the  acute  symptoms  have  merely  super- 
vened upon  a  chronic  complaint.  Such  cases  are  puzzling;  it  may 
be  indeed  impossible  to  arrive  immediately  at  their  solution,  and 
we  have  to  wait  until  the  acute  symptoms  subside,  before  the 
diagnosis  is  determined.  Sometimes,  however,  an  accurate  inquiry 
into  the  history  of  the  affection  will  lead  to  a  knowledge  of  the 
real  condition, — still,  far  from  always;  for  the  malady  may  have 
been  latent  and  have  scarcely  attracted  the  patient's  attention. 
In  hepatic  cancer  the  sudden  and  rapid  development  of  the 
malady  amid  the  signs  of  acute  congestion  is  not  very  uncommon. 
Occasionally  the  peculiar  physical  phenomena  of  individual  he- 
patic diseases,  such  as  the  nodular  tumors  of  a  malignant  growth, 
or  the  fluctuation  of  an  hydatid  cyst,  will  assist  materially  in  the 
diagnosis. 

Acute  Non-hepatic  Diseases  with  Jaundice. — There  are  many 
acute  affections,  such  as  pneumonia,  pyaemia,  puerperal  fever,  and 
some  forms  of  poisoning,  in  which  jaundice  may  coincide  with 
febrile  symptoms  and  excite  suspicions  of  acute  hepatitis,  or,  at  all 
events,  of  an  extreme  degree  of  acute  hepatic  congestion.  But  the 
yellowness  of  the  skin  which  may  attend  the  non-hepatic  disorders 
mentioned  is  accompanied  by  symptoms  so  different  from  those 
connected  with  the  jaundice  of  acute  inflammation  of  the  liver, 
that  a  mistake  is  not  likely  to  arise  if  the  history  of  the  case  be 
taken  into  account  and  other  viscera  besides  the  liver  be  explored. 

*  Aitken's  Practice  of  Medicine,  vol.  ii. 


558  MEDICAL    DIAGNOSIS. 

Diaphragmatic  Pleurisy. — The  manifestations  of  inflammation 
of  the  pleural  covering  of  the  diaphragm  are  in  several  respects 
similar  to  those  of  inflammation  of  the  liver.  We  find  in  this 
dangerous  complaint  pain  in  the  right  hypochondrium,  nausea 
and  vomiting,  cough  and  embarrassed  respiration,  occasionally 
jaundice, — much  the  same  symptoms  which  we  observe  in  hepa- 
titis, especially  if  the  serous  envelope  of  the  liver  be  at  the  same 
time  implicated.  But  the  pain  in  diaphragmatic  pleurisy  is  greater, 
more  suddenly  developed,  and  is  much  more  aggravated  by  move- 
ments and  by  full  inspiration ;  the  diaphragm  on  one  side  is  im- 
movable, the  breathing  is  purely  costal,  and  difficulty  in  breathing 
amounts  to  orthopncea;  we  frequently  encounter  hiccough  and 
great  anxiety,  sometimes  a  sardonic  grin  on  the  features,  and  the 
cough  comes  on  in  paroxysms.  And  although,  as  a  case  recorded 
by  Andral*  proves,  there  may  be  jaundice,  yet  this  is  in  reality  so 
generally  wanting  as  scarcely  to  belong  to  the  symptoms  of  dia- 
phragmatic pleurisy.  Then  in  this  complaint  we  may  find  fric- 
tion sounds, — though  the  physical  signs  will  not  always  aid  us, 
being,  as  the  febrile  excitement  is,  often  but  slight  and  uncertain, f 
and  consisting  simply  in  enfeebled  breathing,  with  perhaps  a  few 
fine  moist  rales  at  the  lower  portion  of  one  side  of  the  chest.  On 
the  other  hand,  the  fever  with  these  imperfect  physical  signs  may 
be  very  marked.  There  is  generally,  in  addition  to  the  pain  along 
the  cartilages  of  the  false  ribs,  a  tender  spot  in  the  epigastrium,  on 
a  level  with  the  tenth  rib,  one  or  two  finger-breadths  from  the 
linea  alba.  There  are  shooting  pains  along  the  clavicle  and  in  the 
tract  of  the  superficial  cervical  plexus,  and  the  phrenic  nerve  of 
the  affected  side,  pressed  on  in  the  neck,  is  very  sensitive.  The 
pain  on  pressure  is  generally  most  intense  along  the  costal  inser- 
tions of  the  diaphragm,  especially  of  the  tenth  rib;  it  is  stated 
that  upward  pressure  affords  a  means  of  diagnosis,  as  it  relieves 
the  pleuritic  pain. J 

Inflammation  of  the  Biliary  Passages  ;  Acute  Yellow  Atrophy. — 
Both  of  these  maladies  may  be  readily  confounded  with  hepatitis. 
But  the  former,  although  presenting  more  jaundice  than  the  other 
maladies  of  the  group  now  under  discussion,  is  otherwise  so  similar 

*  Clinique  Medieale,  tome  ii. 

f  Cases  by  Habershon,  Guy's  Hospital  Reports,  1869. 

X  British  Medical  Journal,  Aug.  1871. 


DISEASES    OF    THE    LIVER.  559 

that  it  may  be  classed  with  them,  and  will  be  described  as  one 
of  the  main  affections  of  this  group;  the  other  belongs  clinically 
to  a  different  section, — namely,  among  diseases  characterized  by 
decrease  in  size  of  the  liver;  and  it  is  there  that  we  shall  point 
out  its  differences  from  acute  hepatitis. 

Inflammation  of  the  Gall-Bladder  and  Gall-Ducts. — 

Inflammation,  when  it  attacks  the  biliary  passages,  is  most  apt  to 
affect  the  gall-bladder  and  the  ductus  choledochus.  Frequently 
the  morbid  process  is  propagated  from  the  stomach  or  intestines, 
and  nausea,  furred  tongue,  a  feeling  of  weight  in  the  epigastrium, 
feverishness,  and  diarrhoea,  occur  previously  to  the  discoloration 
of  the  fseces,  to  the  jaundice,  to  the  increased  hepatic  dnlness,  and 
to  the  slight  tenderness  on  pressure  in  the  right  hypochondrium ; 
in  other  words,  the  symptoms  of  gastric  or  gastro-intestinal  catarrh 
precede  those  of  "icterus  catarrhalis," — by  far  the  most  common 
form  of  inflammation  of  the  gall-bladder;  for  suppurative  inflam- 
mation is  very  rare. 

Catarrhal  icterus  does  not  cause  any  great  enlargement  of  the 
liver,  and  the  swollen  organ  remains  smooth  on  palpation.  Nor 
is  the  tenderness  decided,  except  over  the  tumid  and  projecting 
gall-bladder.  The  jaundice,  at  first  slight,  becomes  after  a  few 
days,  as  the  bile-ducts  are  obstructed,  intense,  and  the  stools  are 
white  and  devoid  of  bile.  There  is  now  no  fever,  and  usually  a 
slow  pulse.  The  affection  is  the  most  common  cause  of  marked 
jaundice  in  young  persons ;  when  found  in  the  middle-aged  or  in 
the  old  it  is  apt  to  be  associated  with  a  gouty  diathesis  or  to  have 
followed  syphilis;  and  at  any  age  it  may  be  secondary  to  other 
diseases  of  the  liver,  and  is  then  apt  to  be  lasting. 

Generally  catarrhal  icterus  is  a  tractable  disorder ;  and  after 
continuing  for  two  or  three  weeks,  it  usually  subsides.  But  it 
may  persist  for  as  many  months ;  and  in  rare  instances  the  inflam- 
mation leads  to  an  occlusion  of  the  bile-ducts,  and  to  a  fatal  issue. 
I  had  such  a  case  in  1863  under  my  charge  at  the  Philadelphia 
Hospital.  The  patient,  a  man  upwards  of  sixty  years  of  age,  died 
deeply  jaundiced  and  comatose.  He  had  presented,  during  life, 
the  signs  of  enlargement  of  the  liver;  little  or  no  tenderness  in 
the  hepatic  region;  no  fever;  but  much  gastric  irritability  and 
obstinate  constipation,  both  of  which  had  existed  for  three  weeks 
prior  to  a  noticeable  discoloration  of  the  skin.     The  whole  disease 


560  MEDICAL    DIAGNOSIS. 

was,  as  far  as  could  be  ascertained,  of  only  two  months'  duration ; 
and  the  jaundice  steadily  deepened  from  the  time  of  its  first  ap- 
pearance. At  the  autopsy,  the  gall-bladder  was  found  enormously 
distended,  its  coats  thin,  yet  otherwise  scarcely  abnormal ;  but  the 
common  duct  was  obliterated  by  inflammation.  The  stomach  and 
the  upper  bowel  were  congested,  while  the  coats  of  the  stomach 
toward  the  pylorus  were  thickened.  A  similar  case  has  been 
recently  described  by  Tyson.* 

Now,  in  point  of  diagnosis,  it  is  not  generally  difficult  to  dis- 
tinguish the  catarrhal  inflammation  of  the  gall-bladder,  except  in 
those  rare  instances  in  which  the  common  duct  or  the  hepatic  duct 
is  obliterated.  It  differs  from  hepatic  inflammation  chiefly  by  the 
marked  jaundice  and  by  the  absence  of  fever  and  of  grave  consti- 
tutional disturbance ;  from  the  ordinary  congestion  of  the  liver,  by 
the  different  etiological  elements  in  the  history  of  the  case, — the 
one  disorder  happening  most  commonly  in  connection  with  disease 
of  the  heart,  or  an  obstruction  of  the  portal  circulation,  or  a  mias- 
matic poison,  the  other  following  most  usually  exposure  to  cold 
and  damp  or  the  eating  of  quantities  of  indigestible  food,  or  oc- 
curring in  an  epidemic  form.  Then,  inflammation  of  the  gall- 
ducts  gives  rise  to  much  more  jaundice.  Further,  we  must  not 
forget  that  what  is  called  congestion  is  often  really  the  disease  we 
are  discussing. 

From  the  jaundice  of  chronic  hepatic  maladies — such  as  cancer 
or  cirrhosis — we  separate  catarrhal  icterus  by  the  non-existence  of 
the  significant  physical  signs  of  these  maladies,  by  its  acute  course, 
and  by  the  dissimilar  progress  of  the  symptoms.  Still,  as  regards 
cancer  we  must  bear  in  mind  that  we  encounter  in  elderly  gouty 
persons  cases  of  long-persisting  catarrhal  icterus  attended  with 
frequent  vomiting  and  marked  emaciation  which  strongly  resem- 
ble cancer,  yet  slowly  yield  to  treatment.  Inflammation  of  the 
biliary  passages  and  the  jaundice  arising  in  consequence  of  biliary 
calculi  are  distinguished  by  the  severe  pain,  the  sudden  appear- 
ance of  the  icterus  subsequent  to  the  paroxysms  of  pain,  its  in- 
crease after  such  paroxysms,  and  its  often  rapid  fading  after  the 
gall-stone  is  voided.  The  symptoms  of  the  early  stages  of  acute 
atrophy  of  the  liver,  as  well  as  those  of  some  cases  of  acute  inflam- 

*  Transactions  of  the  Pathological  Society  of  Philadelphia,  vol.  iv. 


DISEASES    OF    THE    LIVER.  561 

niation,  may  be  so  like  the  symptoms  of  inflammation  of  the  gall- 
bladder and  gall-ducts  that  their  discrimination  is  for  a  time 
impossible;  but  the  different  constitutional  phenomena  which 
soon  follow  clear  up  the  obscurity. 

Acute  Diseases  characterized  by  a  Decrease  in  the  Size  of  the 
Liver  and  by  Deep  Jaundice. 

Acute  Yellow  Atrophy. — This  dangerous  affection  consists 
in  a  rapid  diminution  in  size  of  the  liver,  with  changes  in  its 
secreting-cells,  amounting  often  to  their  complete  disintegration. 
The  functions  of  the  liver  are,  in  consequence,  almost  wholly  sus- 
pended, and  the  evil  effects  of  the  accumulation  of  the  elements 
of  the  bile  in  the  blood  show  themselves  plainly  in  the  deep 
jaundice,  and  in  the  profound  disturbance  of  the  nervous  system. 
To  this  disease  belong  most  of  those  cases  of  malignant  jaundice 
which  terminate  rapidly  in  death  after  violent  cerebral  symptoms. 
The  malady  scarcely  ever  lasts  a  week ;  generally  a  few  days  only 
elapse  before  the  patient  becomes  comatose  and  dies. 

The  complaint  is  sometimes  ushered  in  by  nausea,  a  coated 
tongue,  irregular  action  of  the  bowels,  and  a  frequent  pulse;  at 
other  times  it  begins  abruptly  with  pain  in  the  head,  and  with 
vomiting,  at  first  the  contents  of  the  stomach,  but  soon  of  coffee- 
ground  material,  which  is  evidently  altered  blood.  The  skin  is 
yellow,  and  becomes  from  hour  to  hour  more  discolored.  Jaun- 
dice is,  indeed,  never  absent:  it  may  not  make  its  appearance 
before  the  other  urgent  symptoms,  but  sometimes  it  precedes  the 
signs  of  serious  difficulty  for  several  days,  or  even  for  longer, — 
perhaps  for  upwards  of  two  weeks.*  That  the  jaundice  is  not  due 
to  obstruction  is  proved  by  the  stools  containing  bile.  There  are 
not  uncommonly  pain  at  the  epigastrium  and  in  the  hepatic  region, 
muscular  and  arthritic  pains,  dyspnoea,  meteorism,  enlargement 
of  the  spleen,  epistaxis,  and  hemorrhage  from  the  bowels.  The 
pulse  exhibits  extraordinary  changes :  it  is  generally  very  rapid, 
but  sinks  at  times,  without  any  assignable  reason,  to  a  normal  fre- 
quency ;  during  the  deep  coma  of  the  last  stages  of  the  malady  the 
beat  of  the  artery  is  apt  to  become  slow  and  full,  but  it  may  be 
very  quick  and  very  small.     There  is  fever,  not,  however,  active 

*  As  in  Observation  No.  XVII.  of  Frerichs  on  Diseases  of  the  Liver.' 

36 


562  MEDICAL    DIAGNOSIS. 

or  presenting  a  marked  rise  in  the  temperature  ;  this  may  be,  in- 
deed, after  the  early  stages  of  the  disease,  below  the  norm.  The 
surface  may  be  covered  with  petechia?,  on  account  of  the  dissolu- 
tion of  the  blood.  But,  if  Ave  except  perhaps  the  deep  jaundice 
and  the  lessening  hepatic  dulness,  the  most  significant  symptoms 
are  those  referable  to  the  nervous  system.  Severe  headache,  de- 
lirium, involuntary  discharges,  tremors,  spasms,  convulsions,  or  a 
constantly-increasing  stupor  and  sluggish  pupils,  show  clearly  what 
disturbance  the  poisoned  blood  is  creating  in  the  nervous  centres. 

Acute  atrophy  of  the  liver  scarcely  happens  in  children  or  after 
forty  years  of  age,  and  is  much  more  common  in  women  than  in 
men.  "We  find  it  not  unusually  following  violent  mental  emotions 
or  drunkenness  and  venereal  excesses;  or  it  occurs  during  preg- 
nancy, and  is  then  accompanied  by  renal  disorder. 

Now,  how  does  this  fatal  malady  differ  from  acute  inflammation 
of  the  liver  f  By  the  marked  jaundice,  the  cerebral  symptoms, 
the  rapid  diminution  in  the  volume  of  the  liver,  the  dry,  brown 
tongue,  the  frequent,  changeable  pulse,  and  the  occurrence  of  hem- 
orrhages. Then  the  circumstances  under  which  acute  atrophy 
makes  its  appearance  are  very  dissimilar. 

Indeed,  the  diagnosis  is  not  generally  a  difficult  one;  not  nearly 
so  difficult  as  between  acute  atrophy  and  typhoid  fever,  or  between 
the  former  affection  and  yellow  fever  or  certain  local  diseases,  such 
as  peritonitis,  pneumonia,  and  meningitis,  when  accompanied  by 
jaundice  and  delirium.  The  character  of  the  eruption,  the  pres- 
ence of  diarrhoea  instead  of  constipation,  the  milder  nature  of 
the  mental  wandering,  the  significant  temperature  record,  and  the 
slower  progress  of  the  disease  are  of  much  value  in  enabling  us 
to  distinguish  between  typhoid  fever  and  the  typhoid  symptoms  of 
acute  yellow  atrophy  of  the  liver.  From  yellow  fever,  acute  atrophy 
differs  by  the  epidemic  character  of  the  former  and  the  different 
circumstances  under  which  it  arises,  by  the  injected  eye,  by  the 
intense  pain  in  the  back,  limbs,  and  forehead,  by  the  stages  the 
febrile  malady  presents,  by  the  high  fever  temperature,  by  the 
comparative  absence  of  cerebral  symptoms,  and  by  the  enlarge- 
ment rather  than  the  atrophy  of  the  liver. 

From  the  other  affections  named,  the  hepatic  disorder  may  be 
discriminated  by  a  thorough  examination  of  the  various  organs 
of  the  body,  and  by  a  careful  weighing  of  all  the  symptoms.     In 


DISEASES    OF    THE    LIVER.  563 

truth,  it  is  thus  only  that  we  can  avoid  error ;  since,  unless  we  can 
establish  the  most  positive  sign  of  acute  atrophy, — the  diminution 
of  the  area  of  percussion  dulness  of  the  liver,  and  there  are 
cases  in  which  we  cannot  establish  this,  particularly  if  there  have 
been  enlargement  from  previous  disease, — there  is  no  manifestation 
of  the  hepatic  malady  that  may  not  occur  in  the  diseases  mentioned, 
when  these  are  complicated  by  jaundice.  It  is  true  that  vomiting 
of  blood  is  scarcely  among  their  symptoms ;  but  this  does  not  in- 
variably happen  in  acute  atrophy.  In  many  cases  of  doubt  we 
may  turn  to  account  the  researches  of  Frerichs  on  the  character 
of  the  urine  in  this  complaint,  and  seek  in  the  urinary  secretion 
for  the  sediments  of  tyrosine  or  for  leucin ;  and  test  for  urea,  which 
is  greatly  deficient  or  absent.  So  may  be  the  uric  acid,  the  chlo- 
rides, the  sulphates,  and  the  earthy  phosphates.  We  may  in  this 
connection  remark  that  leucin  and  tyrosine  have  also  been  found 
in  the  blood  and  in  many  tissues  of  the  body.  This  happened  in 
a  case  which  I  saw  with  Dr.  H.  C.  Wood,  and  which  he  has  care- 
fully reported.* 

Acute  yellow  atrophy  may  happen  occasionally  in  children.f 
An  aifection  like  it  occurs  from  phosphorus-poisoning;  and  in- 
deed there  are  those  who  believe  that  acute  yellow  atrophy  is  really 
due  to  phosphorus  accidentally  introduced  into  the  system,  while 
others  look  upon  the  liver  disorder  as  merely  forming  part  of  a 
general  disease. 

The  occurrence  of  the  fatal  malady  in  pregnant  women  has 
already  been  alluded  to.  Now,  jaundice  from  mental  emotion, 
or  produced  by  the  pressure  of  the  gravid  womb,  is  in  them  not 
unusual;  and  we  may  be  called  upon  to  distinguish  this  simple 
and  harmless  form  of  icterus  from  that  of  yellow  atrophy.  In 
the  serious  derangement  of  the  nervous  system,  and  the  graver 
character  of  all  the  symptoms,  lie  the  marks  of  separation. 

Chronic  Diseases  attended  with  Enlargement  of  the  Liver,  and 
with  slight  or  no  Jaundice. 

Chronic  Congestion. — This  morbid  condition  is  observed 
chiefly  in  persons  of  sedentary  habits  who  do  not  sufficiently  oxy- 

*  American  Journal  of  the  Medical  Sciences,  April,  1867. 

f  Duckworth,  St.  Barthol.  Hosp.  Eep.3  vol.  vi. ;  Tuckwell,  ibid.,  vol.  x.,  1874. 


564  MEDICAL    DIAGNOSIS. 

genate  their  blood,  or  in  those  who  indulge  too  freely  in  the  pleas- 
ures of  the  table,  or  use  large  quantities  of  alcoholic  drinks  or 
fermented  liquors.  It  is  frequently  met  with  in  hot  climates  and 
in  malarial  districts.  It  may  also  occur  in  scurvy,  and  in  con- 
nection with  abdominal  affections  which  interfere  with  the  portal 
circulation  and  thus  produce  a  fulness  of  the  blood-vessels  of  the 
liver;  or  it  may  happen  in  consequence  of  a  disturbance  of  the 
flow  of  blood  through  the  liver,  dependent  upon  disease  of  the 
heart. 

Whatever  the  source  of  the  hyperemia,  the  symptoms  are  simi- 
lar. They  are  impaired  appetite,  bitter  taste  in  the  mouth,  a 
coated  tongue,  flatulency,  a  feeling  of  tension  and  weight  in  the 
right  hypochondrium,  depression  of  spirits,  loss  of  strength,  im- 
poverishment of  blood,  deposits  of  lithates  in  the  highly-colored 
urine  on  cooling,  headache,  dry  cough,  and  occasional  nausea  and 
diarrhoea,  or  looseness  of  the  bowels  alternating  with  constipation, 
and  in  protracted  cases  haemorrhoids.  The  conjunctiva  has  con- 
stantly a  more  or  less  jaundiced  tinge ;  the  dulness  on  percussion 
in  the  hepatic  region  is  increased  in  extent.  In  some  cases  the 
habitual  congestion  leads  to  an  altered  condition  of  the  bile-ducts 
and  of  the  secreting-cells  of  the  liver;  but  ordinarily,  unless  the 
hyperemia  be  kept  up  by  some  exciting  cause  which  it  is  impos- 
sible to  remedy, — such  as  an  abdominal  tumor,  or  an  organic 
affection  of  the  heart, — we  can,  by  a  carefully  regulated  diet  and 
by  active  exercise  in  the  open  air,  together  with  the  use  of  laxa- 
tives, restrain  the  congestion,  and,  indeed,  in  time  remove  it.  A 
troublesome  feature  of  the  malady  is  its  disposition  to  return. 

By  attention  to  the  signs  mentioned,  there  is  usually  little  diffi- 
culty in  recognizing  chronic  hepatic  congestion.  How  it  may  be 
discriminated  from  other  forms  of  enlargement  of  the  liver,  we 
shall  presently  inquire.  It  is  sometimes  confounded  with,  or 
rather  there  is  sometimes  mistaken  for  it,  a  liver  which  has  been 
pushed  downward  by  the  habit  of  tight  lacing.  But  the  absence 
of  any  signs  of  hepatic  derangement,  and  the  lowered  outline  of 
the  upper  border  of  the  displaced  right  lobe,  will  generally  enable 
us  to  distinguish  this  state  from  chronic  congestion  of  the  liver. 

Chronic  hepatic  congestion,  as  indeed  any  disease  of  the  liver 
which  leads  to  its  enlargement,  may  be  confounded  with  chronic 
gastritis,  and  on  account  mainly  of  the  fulness  in  the  epigastric 


DISEASES    OF    THE    LIVER.  565 

region  which  may  happen  in  the  hepatic  malady.  The  error  is 
most  likely  to  occur  in  those  cases  of  enlarged  liver  in  which  there 
is  pain  on  pressure.  But  the  outline  of  the  dulness  when  the  liver 
is  increased  in  size,  the  jaundiced  hue  of  the  conjunctiva,  the 
altered  character  of  the  stools,  and,  on  the  other  hand,  the  more 
marked  indigestion,  and  the  fulness  and  tenderness  being  equally 
perceived  in  positions  to  which  the  liver,  unless  greatly  augmented, 
does  not  extend,  will  ordinarily  enable  us  to  arrive  at  a  correct 
diagnosis.  Yet  in  attempting  to  do  so  we  must  not  forget  that  the 
two  morbid  states  may  be  conjoined. 

Hypertrophy  of  the  liver  may  present  the  manifestations  of  con- 
gestion. The  little  we  know  of  an  increased  formation  of  the 
liver-cells  teaches  us  that  this  may  happen  as  a  partial  hyper- 
trophy, to  compensate  for  loss  of  substance,  in  instances  in  which 
a  portion  of  the  gland  has  been  destroyed ;  or  as  a  more  general 
increased  growth  in  diabetes,  in  leucocythsemia,  and  as  a  conse- 
quence of  malaria.  Perhaps  the  history  of  the  case  may  enable 
us  to  arrive  at  the  discrimination  of  the  rare  disease.  Yet  there 
is  never  any  certainty  in  the  diagnosis:  in  truth,  we  cannot  be 
said  to  possess  the  means  which  would  enable  us  at  the  bedside  to 
distinguish  hypertrophy  of  the  liver  from  other  forms  of  hepatic 
enlargement. 

So-called  torpor  of  the  liver,  in  which  there  is  supposed  to  be  a 
deficient  excretion  of  bile,  has  much  the  same  symptoms  as  con- 
gestion. Indeed,  it  is  a  question  whether  this  is  not  often  present 
as  at  least  a  secondary  result.  In  persons  of  middle  life  who  eat 
freely  and  take  too  little  exercise  in  the  open  air,  or  those  of  sed- 
entary habits  in  whom  anxiety  and  worry  have  lowered  the  nervous 
tone,  the  well-known  symptoms  of  headache,  languor,  depression 
of  spirits,  loss  of  appetite,  drowsiness  after  meals,  sallow  hue  of 
skin,  dingy  conjunctiva,  urine  depositing  lithates,  stools  black  and 
offensive,  or  more  often  pale  or  whitish,  bespeak  this  "bilious" 
state,  and  we  can  only  distinguish  the  functional  disorder  from 
the  ordinary  forms  of  chronic  congestion  by  the  history,  the  con- 
current symptoms,  the  tension  in  the  region  of  the  liver,  and 
the  enlargement  of  the  organ,  which  these  present. 

The  symptoms  of  chronic  congestion  of  the  liver,  as  indeed  of 
other  hepatic  derangements,  show  themselves  at  times  more  par- 
ticularly in  the  nervous  system.     Headache,  vertigo,  dimness  of 


566  MEDICAL    DIAGNOSIS. 

sight,  and  noises  in  the  ears  are  common ;  and  I  have  often  known 
the  same  to  happen  that  Murchison  states  to  be  not  infrequent, — 
I  have  known  tingling  and  pricking  sensations  and  a  feeling  of 
creeping  in  the  extremities  cause  needless  alarm  that  paralysis  is 
imminent,  and  disappear  under  blue  pill  and  a  few  saline  pur- 
gatives. On  the  other  hand,  we  must  be  careful  not  to  regard 
as  evidence  of  an  hepati  cdisorder  signs  of  stomach  and  liver  de- 
rangement which  are  really  due  to  an  affection  of  the  nervous 
system.  I  have  twice  known  altered  character  of  the  stools,  bitter 
taste  in  the  mouth,  vomiting,  and  slight  discoloration  of  the  con- 
junctiva, existing  in  connection  with  tumors  at  the  base  of  the 
brain,  considered  as  purely  of  hepatic  origin.  Clifford  Allbutt* 
cites  a  case  of  Meniere's  disease,  in  the  person  of  a  physician, 
where  the  vomiting  and  giddiness  received  this  false  explanation. 
In  such  instances,  of  course,  attention  to  the  occurrence  of  dis- 
ordered gait,  and  of  the  persistent  noises  in  one  or  both  ears,  and 
to  the  loss  of  power  of  hearing  of  one  ear,  particularly  shown 
when  a  watch  or  a  tuning-fork  is  placed  in  contact  with  the  skull 
on  the  affected  side,  tells  the  true  meaning  of  the  other  symptoms. 

Chronic  Hepatitis. — It  is  difficult  to  say  what  are  the  symp- 
toms of  the  malady,  because  of  the  latitude  which  has  been  given 
to  the  term  chronic  hepatitis,  under  which  have  been  ranged  most 
of  the  chronic  affections  of  the  organ, — especially,  however,  the 
congested,  the  fatty,  and  the  albuminoid  liver.  If,  following 
Andral,  we  call  onlv  that  state  chronic  inflammation  in  which  the 
liver  is  augmented  in  size,  harder  than  natural,  yet  easily  torn,  of 
deep-red  color,  and  in  which  the  exudation  is  apt  to  become  puru- 
lent, we  find  these  manifestations:  dull,  heavy  pain  in  the  hepatic 
region,  somewhat  augmented  by  pressure;  dry,  heated  skin,  of 
sallow  hue,  and  often  the  seat  of  distressing  itching;  a  yellowish 
conjunctiva;  indigestion;  whitish  stools,  generally  hard;  a  short 
cough;  and  the  physical  signs  on  palpation  and  percussion  of  an 
enlarged  liver,  the  border  of  which  is  uniformly  thickened  and 
hardened. 

The  inflammation  may  be  chronic  in  its  course  almost  from  its 
onset,  and  be  developed  under  much  the  same  circumstances  as 
chronic  congestion ;  or  it  may  succeed  to  an  attack  of  acute  hepa- 

*  St.  George's  Hosp.  Rep.,  vol.  viii. 


DISEASES    OF    THE    LIVER.  567 

titis.  But  chronic  hepatitis  is  not  a  common  disease,  except  in 
hot  climates,  and  is  scarcely  to  be  distinguished  from  persistent 
hyperemia  of  the  organ,  unless  when  the  inflammation  leads  to 
the  formation  of  abscesses. 

Abscess  of  the  Liver. — Hepatic  abscesses,  as  we  have  already 
seen,  may  form  as  the  result  of  either  acute  or  chronic  inflamma- 
tion of  the  liver.  In  the  tropics  this  is  a  not  unusual  termination 
of  the  inflammation ;  in  temperate  climates  we  seldom  encounter  the 
affection,  save  as  the  consequence  of  metastatic  or  pysemic  inflam- 
mation of  the  liver,  or  in  connection  with  some  disease  of  the  in- 
testines, or  as  a  sequel  of  gall-stones  which  have  produced  ulcera- 
tion of  the  gall-bladder  and  gall-ducts,  and  secondary  abscesses  of 
the  liver. 

The  symptoms  of  hepatic  abscess  are  obscure  ;  indeed,  the  collec- 
tion of  pus  may  take  place  in  the  liver  without  causing  scarcely 
any  phenomena  which  direct  attention  to  the  viscus.  Sometimes 
the  only  symptoms  are  debility,  great  irritability  of  the  nervous 
system,  and  irregular  slight  febrile  attacks.  More  usually  the 
formation  of  pus  gives  rise  to  rigors,  quickens  the  pulse  very 
much,  leads  to  night-sweats,  and  not  unfrequently  to  the  develop- 
ment of  a  fever  simulating  that  of  a  quotidian  or  tertian  intermit- 
tent or  remittent,  and  attended  during  certain  hours  of  the  day 
with  considerable  elevation  of  temperature. 

Jaundice  occurs,  but  is  generally  slight,  and  is  often  entirely 
absent.  There  is  no  enlargement  of  the  abdominal  veins,  nor  is 
there,  save  quite  exceptionally,  ascites  or  oedema  of  the  lower  ex- 
tremity. Dry  cough,  quickened  breathing,  and  gastric  disorder, 
especially  loss  of  appetite,  are  frequent,  and  obstinate  vomiting  is 
not  unusual.  In  the  advanced  stages  of  the  malady  typhoid 
symptoms  are  apt  to  develop.  But  all  these  manifestations  may 
be  ill  defined  and  the  disease  latent. 

The  local  signs,  too,  are  far  from  being  always  very  obvious,  or 
indeed  very  uniform.  In  some  instances  the  hepatic  region  is  more 
prominent  than  natural,  and  we  can  detect  fluctuation  over  por- 
tions of  the  enlarged  gland ;  but  neither  sign  is  constant,  and  the 
latter  depends  greatly  upon  whether  or  not  the  abscess  be  deeply 
seated  in  the  hepatic  parenchyma.  Tenderness,  either  general  or 
limited  to  a  particular  spot,  is  found  only  in  a  certain  proportion 
of  cases,  especially  when  the  abscess  is  near  the  surface.     It  is  fre- 


568  MEDICAL    DIAGNOSIS. 

quently  associated  with  a  throbbing  or  a  dull  pain,  which  may  be 
transmitted  to  the  right  shoulder.  According  to  Annesley,*  this 
sympathetic  pain  in  the  right  shoulder  indicates  that  the  convex 
part  of  the  right  lobe  of  the  viscus  is  affected.  Conjoined  to  the 
feeling  of  weight,  and  to  the  throbbing  in  the  hepatic  region,  is  at 
times  a  tension  occasioned  by  palpation  of  the  abdominal  muscles, 
especially  of  the  rectus.  Twiningf  regards  this  circumstance  as  a 
very  significant  manifestation  of  deep-seated  abscess. 

But  a  positive  diagnosis  of  abscess  of  the  liver  is  often  a  very 
difficult  matter;  for  there  are  a  number  of  other  affections  with 
which  it  may  be  readily  confounded.  Prominent  among  these  are 
hydatids,  cancer  of  the  liver,  affections  of  the  gall-bladder,  and  a 
pleuritic  effusion  on  the  right  side. 

From  hydatids  of  the  liver,  the  febrile  symptoms,  the  disturbed 
nutrition,  and  the  pain  distinguish  an  hepatic  abscess,  except  in 
those  cases  in  which  the  cyst  becomes  the  seat  of  suppuration. 
Under  these  circumstances  error  can  scarcely  be  avoided,  unless 
we  are  fully  cognizant  of  the  history  of  the  patient,  and  are  in 
possession  of  facts  furnishing  clear  evidence  as  to  the  state  of  the 
liver  prior  to  the  formation  of  pus. 

Cancer  of  the  liver  differs  from  an  abscess  by  its  dissimilar 
history,  by  the  hard  nodular  masses,  and  by  the  absence  of  fluc- 
tuation. It  is  only  in  rapidly  growing  medullary  cancer  that  we 
can  discern  a  sense  of  fluctuation ;  but  even  here  we  can  generally 
distinguish  some  nodules  which  do  not  fluctuate;  and  should  the 
soft  cancerous  matter  impart  to  the  finger  a  feeling  of  fluctuation, 
it  is  very  rarely  as  distinct  as  that  of  an  abscess.  Further,  the 
marked  febrile  phenomena  and  the  other  constitutional  symptoms 
are  not  like  what  occur  in  hepatic  cancer;  for  in  this  affection,  as 
in  all  cancers,  the  temperature  is  but  little  affected, — may,  indeed, 
be  rather  low. 

Of  the  diseases  of  the  gall-bladder,  the  one  which  is  most  liable 
to  be  confounded  with  hepatic  abscess  is  distention  of  the  bladder. 
This  occurs  either  from  a  closure  of  the  cystic  or  of  the  common 
duct,  especially  from  the  former,  or  from  an  inflammation  of  the 
gall-bladder  itself,  and  perhaps  a  subsequent  closure  of  the  ducts. 
In  such  a  case  the  gall-bladder  may  become  enormously  distended 

*  Researches  into  the  Diseases  of  India.  f  Diseases  of  Bengal. 


DISEASES    OF    THE    LIVER.  569 

with  irritating  and  decomposing  bile  and  puriform  matter,  and 
thus  may  be  occasioned  a  fluctuating  tumor,  tender  on  pressure, 
and  readily  mistaken  for  an  abscess. 

Now,  we  are  sometimes  able  to  distinguish  the  soft  swelling 
caused  by  a  diseased  gall-bladder  by  its  situation,  its  pear-shaped 
form,  its  mobility  and  the  absence  of  adhesions  to  the  abdominal 
walls,  its  distinct  and  persistent  fluctuations ;  by  its  never  having 
been  hard  ;  by  the  normal  appearance  of  the  parietes  of  the  abdo- 
men ;  by  the  absence  of  tenderness  over  the  liver,  merely  tenderness 
over  the  tumor  being  found  ;  and  by  the  fact  that  affections  of  the 
gall-bladder  are  frequently  preceded  by  repeated  attacks  of  violent 
pain  due  to  the  passage  of  biliary  calculi,  or  by  bilious  fever.  Then 
we  find  very  little  jaundice,  or  none  at  all ;  and  no  hectic  fever. 
But  to  neither  of  these  circumstances  can  we  trust  implicitly. 
For  there  is  apt  to  be  intense  jaundice  in  an  affection  of  the  gall- 
bladder, if  the  common  duct  also  be  implicated ;  and  jaundice  is, 
in  abscess  of  the  liver,  a  symptom  more  frequently  absent  than 
present.  And  with  reference  to  hectic  fever,  the  continued  sup- 
puration in  the  distending  sac  may  produce  it,  and  lead,  indeed, 
to  great  constitutional  disturbance.*  Further,  these  biliary  abscesses 
may,  like  hepatic  abscesses,  open  externally,  or  burst  into  the  chest. 
At  times  the  communication  is  with  the  bronchial  tubes,  and  gives 
rise  to  very  anomalous  symptoms.  Thus,  Simmonsf  details  a  case 
in  which  there  was  a  circumscribed  tumor  in  the  epigastrium,  fluc- 
tuating with  a  sense  of  intervening  air  or  gas,  and  resonant  on 
percussion;  a  blowing  sound  was  distinctly  discerned  synchronous 
with  the  respiratory  act,  and  occasionally  accompanied  by  a  gur- 
gling noise;  there  were  profuse  sweats  and  extreme  oppression, 
but  no  signs  of  pneumothorax.  At  the  autopsy  a  biliary  abscess 
was  found  communicating  with  the  right  bronchus. 

As  regards  the  shape  of  the  swelling  due  to  an  enlarged  gall- 
bladder being  diagnostic,  we  must  bear  in  mind  that  it  may  be 
changed  by  contraction  of  the  muscular  coat. 

A  pleuritic  effusion  on  the  right  side  of  the  chest  is  distinguished 
from  an  hepatic  abscess  by  the  same  phenomena  that  we  found,  in 
discussing  pleurisy,  to  separate  this  affection  from  all  forms  of  en- 

*  As  in  a  case  reported  by  the  late  Dr.  Pepper.     American  Journal  of  the 
Medical  Sciences,  Jan.  1857. 
f  American  Journal  of  the  Medical  Sciences,  Oct.  1877. 


570  MEDICAL   DIAGNOSIS. 

largement  of  the  liver.  Bat  abscesses  of  the  liver  may  open  into 
the  right  pleural  cavity.  Then  we  observe  the  physical  signs  of 
a  pleuritic  effusion  subsequent  to  those  of  hepatic  abscess.  Gen- 
erally, too,  the  pus  which  has  made  its  way  through  the  diaphragm 
destroys  the  lung-texture,  until  it  reaches  the  bronchial  tubes,  when 
large  quantities  of  purulent  sputa  are  expectorated  ;  or,  in  rarer 
instances,  it  is  discharged  through  the  walls  of  the  chest.  In  the 
former  case,  the  disturbance  in  the  pleura,  and  the  accumulation 
of  pus  there,  may  be  very  limited  :  the  inflammation  of  the  pleural 
membrane  may  be  circumscribed,  while  the  signs  of  an  inflamma- 
tion at  the  lower  portion  of  the  right  lung,  dulness  on  percussion, 
tubular  breathing,  and  rusty-colored  sputa,  are  evident.  These 
phenomena  may  subside,  and  the  respiration  in  parts  become  inau- 
dible, when  a  discharge  of  a  large  quantity  of  a  reddish  or  whitish 
pas  takes  place,  in  which  the  elements  of  bile  and  the  microscopical 
appearances  of  the  hepatic  tissue  may  be  detected.  Gradually  this 
expectoration  ceases,  and  the  affected  textures  heal.  But  in  some 
instances  the  discharge  never  stops,  and  the  patient  dies  worn  out 
by  the  constant  drain. 

In  what  is  called  subphrenic  pyo-pneumothorax,  cavities  full  of 
air  form  beneath  the  diaphragm  and  extend  into  the  thorax.  When 
situated  on  the  right  side  they  may  be  mistaken  for  the  breaking  of 
an  hepatic  abscess  into  the  chest.  The  history  of  the  affection  is 
generally  very  significant ;  the  subphrenic  abscesses  are  the  result 
of  perforating  ulcers  of  the  stomach  or  of  the  duodenum,  and  their 
development  is  preceded  by  the  symptoms  of  general  peritonitis 
or  by  the  discharge  of  pus  by  the  bowels.  The  signs  of  pneumo- 
thorax, as  Leyden*  has  found,  subsequently  show  themselves,  with 
distinct  metallic  tinkling  and  succussion  sound;  yet,  while  all 
breath-sound  is  sharply  cut  off  below  the  fourth  or  fifth  rib,  up 
to  this  point  the  normal  vesicular  murmur  is  heard  on  deep  respi- 
ration, and  there  are  no  signs  of  pressure  in  the  pleural  cavity  or 
of  distention  of  the  chest,  and  the  marked  alteration,  by  change 
of  position,  of  the  dulness  on  percussion,  from  the  exudation  at 
the  lower  part  of  the  chest,  is  strictly  limited  to  this  part.  The 
liver  reaches  to  the  umbilicus  or  lower,  and  when  a  canula  is 
passed  into  the  cavity  beneath  the  diaphragm  and  a  manometer 

*  Zeitscbrift  fur  Klin.  iled..  Bd.  i. 


DISEASES    OF    THE    LIVEE.  571 

is  attached,  inspiration  shows  increased  pressure,  expiration  the 
reverse, — exactly  opposite,  therefore,  to  what  happens  if  the  canula 
be  in  the  pleura. 

When  an  hepatic  abscess  forces  its  way  externally,  it  may,  prior 
to  its  discharge  through  the  thoracic  or  abdominal  walls,  occasion 
difficulty  in  diagnosis  from  abscesses  originating  in  these  walls. 
Nothing  but  a  careful  consideration  of  the  attending  symptoms 
and  of  the  history  of  the  case  will  lead  to  a  differential  dis- 
tinction. Nor  does  the  difficulty  wholly  cease  when  the  slowly 
developed  tumor,  which  an  hepatic  abscess  forms,  has  opened, 
since  it  is  far  from  always  that  we  find  in  the  pus  the  evidences  of 
the  broken-down  liver-tissue,  and  it  is  only  occasionally  that  the 
fluid  is  of  yellow  or  greenish  color  and  yields  the  reactions  of  bile. 
The  means  of  discrimination  most  to  be  relied  upon  is  a  probe ; 
for  by  the  depth  to  which  it  can  be  passed,  the  direction  it  takes, 
and  the  feel  of  the  structures  it  encounters,  we  are  placed  in  pos- 
session of  many  important  facts  bearing  on  the  diagnosis.  In 
doubtful  cases,  also,  we  may  employ  the  aspirator,  and  a  chemical 
and  microscopical  examination  of  the  pus,  other  than  that  oozing 
out  of  the  opening,  may  tell  the  nature  of  the  abscess.  Indeed, 
the  aspirator  may  be  made  a  means  of  diagnosis  of  abscess  of  the 
liver  under  some  of  the  circumstances  above  mentioned,  where 
abscess  is  closely  simulated  by  other  hepatic  affections.  If  no 
abscess  be  found,  no  particular  harm  results  from  the  explora- 
tion ;  nay,  it  has  even  been  affirmed  that  the  local  depletion  does 
good.* 

Occasionally,  a  hernia  through  one  of  the  recti  muscles  is  mis- 
taken for  a  projecting  abscess  of  the  liver.  I  was  called  some 
years  since  to  see  such  a  case,  in  which  the  opinion  that  it  was  an 
abscess  of  the  liver  had  been  long  entertained.  The  sound  of  the 
mass  on  percussion;  the  clearly-defined  limits  of  the  liver;  the 
absence  of  hepatic  and  gastric  symptoms, — taught  the  true  nature 
of  the  malady. 

Much  has  been  said  by  recent  writers,  especially  by  Murchison, 
of  the  distinction  between  the  abscesses  which  are  developed  in  the 
course  of  pyaemia — "the  pysemic  abscess" — and  the  abscess,  com- 
mon in  tropical  climates,  which  forms  as  the  result  of  hepatitis,  "the 

*  Maclean,  Lancet,  July,  1873. 


572  MEDICAL    DIAGNOSIS. 

tropical  abscess."     The  points  of  distinction  may  be  thus  tabu- 
lated : 

Pyemic  Abscess.  Tropical  Abscess. 

Many  in  number ;  small  in  size.  Usually  a  single  large  abscess. 

Uniform  enlargement  of  liver  ;  only  Enlargement  not  uniform;    bulging 

exceptionally  bulging  of  ribs.  of  ribs,  or  in  epigastrium,  or  in  right 

hypochondrium. 

No  fluctuation  ;  always  pain  and  ten-  Fluctuation  usual ;  pain  and  tender- 

derness.  ness  always  absent. 

Jaundice  present  in  the  majority  of  Jaundice  exceptional. 

cases. 

Enlargement  of  spleen  usual.  Enlargement  of  spleen  unusual. 

Kigors    and    night -sweats    marked;  Kigors  and  night-sweats  less  marked  ; 

great    tendency    to    symptoms    of  obstinate  vomiting  often  present. 

blood-poisoning. 

Course  rapid ;    three  weeks  to  three  Course   less  rapid  ;    often  extends  to 

months.  three  or  six  months,  or  longer. 

Arises    after    external    injuries    and  Arises  in  tropical  climates,  chiefly  in 

operations,    or    internal    suppura-  free  livers ;    dysentery     frequently 

ting  cavities  or   ulcerations,  such  coexists. 

as  ulcers  of  the  stomach  or  gall- 
bladder. 

Fatty  Liver. — A  fatty  liver  occurs  in  drunkards ;  in  persons 
who  lead  indolent  lives  and  are  large  eaters;  in  wasting  diseases, 
especially  in  phthisis;  in  the  course  of  protracted  diarrhoea;  and 
sometimes  in  children  after  exanthematous  fevers.  But  of  all 
these  causes,  pulmonary  consumption  is  the  most  common. 

A  knowledge  of  the  sources  of  fatty  liver  is  the  most  important 
element  in  the  diagnosis;  for  neither  the  physical  signs  nor  the 
symptoms  present  anything  which  is  characteristic.  The  physical 
signs  are  simply  those  of  an  enlarged  liver ;  the  enlargement  is 
generally  moderate  and  uniform,  and  the  lower  margin  rounded. 
In  thin  persons  it  may  be  possible  to  discern  the  doughy  consist- 
ence of  the  organ.  The  symptoms  are  much  the  same  as  those 
of  hepatic  congestion,  except  that  there  is  perhaps  greater  ten- 
dency to  diarrhcea,  and  that  we  find,  in  some  instances,  a  pale, 
greasy-feeling  skin.  There  is  neither  pain  nor  ascites.  The 
amount  of  jaundice  is  always  very  slight;  in  truth,  jaundice  is 
most  frequently  wanting.  Partly  in  consequence  of  the  absence 
of  this  important  symptom,  partly  because  of  the  little  appreciable 
disturbance  a  fatty  liver  may  occasion,  this  morbid  state  at  times 
escapes  our  observation  entirely.     When  there  is  coexisting  fatty 


DISEASES    OF    THE    LIVER.  573 

disease  of  the  heart,  there  is  decided  general  debility,  and  there 
may  be  marked  ansemia. 

Waxy  Liver. — A  peculiar  infiltration  into  the  structure  of  the 
liver,  or  its  degeneration  into  a  substance  rendering  it  firmer  and 
more  glistening,  gives  rise  to  that  appearance  of  the  liver  which 
is  variously  designated  as  waxy,  lardaceous,  amyloid,  albuminous, 
or  scrofulous  liver. 

The  symptoms  of  a  waxy  liver  are  those  of  an  hepatic  derange- 
ment which  manifests  itself  rather  by  the  signs  of  disturbance  of 
other  organs  than  by  the  direct  proof  of  altered  function  of  the 
viscus  really  affected.  Thus,  disordered  digestion,  nausea,  vomit- 
ing, tympanites,  discolored  stools,  and  diarrhoea  are  much  more 
frequent  than  jaundice,  which,  indeed,  is  very  much  oftener  absent 
than  present.  There  is  a  feeling  of  fulness  in  the  hepatic  region, 
but  little  or  no  pain ;  while  physical  exploration  exhibits  an  in- 
creased percussion  dulness,  and  shows  the  dense  organ  to  have  a 
well-defined  though  somewhat  rounded  margin.  The  enlargement 
is  uniform,  but  considerable ;  at  times  so  great  that  the  liver  occu- 
pies a  large  part  of  the  abdomen,  producing  a  visible  bulging. 
The  smoothness  and  the  regularity  of  outline  are  lost  if  waxy 
liver  coexist  with  diseases  of  the  liver  which  may  harden  the 
organ  in  nodules,  such  as  cancer,  fibroid  changes,  or  cirrhosis. 

Enlargement  of  the  spleen  is  commonly  associated  with  the 
enlargement  of  the  liver,  and  in  many  cases  the  urine  is  albumi- 
nous from  waxy  disease  of  the  kidneys.  Dropsy,  as  a  rule,  is  not 
encountered ;  but  in  this  respect  much  depends  upon  the  state  of 
the  kidneys  and  of  the  blood,  or  upon  the  existence  of  secondary 
peritonitis. 

The  etiology  of  a  waxy  liver  teaches  us  that  it  is  very  much 
more  common  in  males  than  in  females ;  that  the  malady  is  usu- 
ally caused  by  constitutional  syphilis ;  that  in  rarer  instances  it  is 
produced  by  tuberculosis;  also  that  it  coexists  with  scrofulous  dis- 
eases of  the  bones,  with  unhealed  ulcers,  with  discharges  from  or 
collections  of  pus  in  various  parts  of  the  body,  with  repeated 
attacks  of  intermittent  fever;  or  that  it  results,  perhaps,  from  the 
abuse  of  mercury.  In  some  cases  we  cannot  trace  the  pathological 
process  to  any  known  cause ;  yet  even  in  these  cases  we  find  it 
attended  with  signs  of  impaired  nutrition  and  occurring  in  persons 
evidently  cachectic. 


574  MEDICAL    DIAGNOSIS. 

The  disease  is  one  lasting  for  years.  In  advanced  cases,  be- 
sides the  spleen  and  the  kidneys,  the  stomach  and  the  intestines 
are  apt  to  be  implicated ;  looseness  of  bowels  with  dysenteric 
symptoms  arise,  and  the  skin  and  breath  have  a  musty,  dis- 
agreeable odor. 

Now,  when  we  contrast  a  waxy  liver  with  other  hepatic  com- 
plaints in  which  the  liver  is  enlarged,  we  find  it  resembling  most 
closely  the  fatty  and  the  syphilitic  affections.  But  in  the  former, 
although  there  is  enlargement,  there  is  not  often  so  much  increase 
in  volume  as  in  the  waxy  liver.  Besides,  the  organ  feels  softer 
on  palpation,  and  the  disorder  is  not  associated  with  a  diseased 
spleen  or  kidney,  and  is  still  less  likely  than  a  waxy  liver  to 
give  rise  to  dropsy.  Then  the  history  of  the  case  is  very  sig- 
nificant. A  syphilitic  hepatitis,  with  which  indeed  the  waxy 
liver  is  at  times  combined,  is  mainly  distinguished  by  the  prom- 
inent nodules  felt  on  the  surface  of  the  liver.  From  congestion 
of  the  liver,  waxy  liver  is  readily  discriminated.  A  compara- 
tively slight  affection  in  which  jaundice  is  frequent  is  very 
different  from  a  malady  in  which  the  hepatic  disease  forms  but 
part  of  a  general  cachexia,  and  in  which  jaundice  is  very  in- 
frequent. 

Cancer  of  the  Liver. — In  cancer  of  the  liver  the  organ  is 
almost  invariably  increased,  and  sometimes  it  reaches  an  enormous 
volume.  The  form  of  the  gland,  too,  is  generally  altered.  It  is 
irregular  and  uneven,  nodules  of  various  size  being  developed  in 
its  substance  and  projecting  from  its  border  and  surfaces.  These 
prominences  are  harder  than  the  surrounding  hepatic  tissue;  but 
there  are  exceptions  to  this  rule,  for  sometimes,  especially  in  the 
encephaloid  variety,  the  elastic  tumors  imjjart,  when  pressed,  a 
very  deceptive  sense  of  fluctuation.  The  cancerous  masses  in- 
crease, and  in  some  cases  with  great  rapidity. 

The  malignant  disease  is  rarely  confined  to  the  liver;  it  fre- 
quently supervenes  upon  cancer  of  the  mammary  gland  or  of  the 
uterus  or  of  the  stomach.  It  is  an  affection  pre-eminently  of 
middle  life  or  of  old  age;  yet  it  occasionally  occurs  in  young 
persons.  I  have  met  with  two  cases  of  primary  cancer  of  the 
liver  in  women  not  twenty-five  years  of  age,  and  two  in  children. 
In  primary  cancer  of  the  liver  we  generally  find  a  history  of 
cancer  in  the  family ;  and  protracted  grief  or  anxiety,  Murchison 


DISEASES    OF    THE    LIVER.  575 

tells  us,*  precedes  the  development  of  the  malady,  whether  a 
family  trait  can  be  traced  or  not.  The  disease  rarely  lasts  beyond 
a  year,  and  it  may  run  a  rapid  course. 

Xow,  many  of  the  pathological  facts  just  mentioned  have  a 
strong  bearing  on  the  diagnosis  of  hepatic  cancer.  They  espe- 
cially throw  light  on  the  most  important  signs  of  the  malady, — 
to  wit,  the  increased  percussion  dulness  in  the  hepatic  region,  and 
the  uneven  surface  detected  on  palpation.  The  enlarged  liver  is 
found  extending  across  the  epigastrium  far  into  the  left  hypo- 
chondrium  ;  it  reaches  at  times  lower  than  the  umbilicus,  and 
presses  the  diaphragm  upward.  The  nodules  can  often  be  felt 
distinctly  through  the  abdominal  walls.  The  diseased  organ  is 
painful,  and  tender  to  the  touch.  In  cases  in  which  the  peritoneal 
covering  is  affected,  the  tenderness  is  greatest.  And,  although 
any  of  these  three  phenomena — the  enlargement,  the  uneven 
surface,  and  the  tenderness — may  be  absent,  they  are  tolerably 
constant  attendants  on  cancer  of  the  liver.  The  tenderness  is, 
I  think,  the  sign  least  frequently  wanting. 

Among  the  symptoms  of  hepatic  cancer,  we  find  gastric  and 
intestinal  disturbances,  pain  in  the  right  shoulder,  rigidity  of  the 
abdominal  muscles,  a  disordered  nutrition  of  the  whole  body,  a 
cachectic  look,  occasional  febrile  attacks,  and,  in  the  later  stages 
of  the  disease,  sometimes  hemorrhages  from  the  stomach  or  bowels, 
and  diarrhoea.  Ascites,  too,  is  observed  among  the  symptoms  of 
the  malignant  malady,  and  is  generally  dependent  either  upon 
chronic  peritonitis  attending  the  development  of  the  cancer,  or 
upon  the  pressure  this  exerts  upon  the  larger  branches  of  the 
portal  vein.  Jaundice  may  or  may  not  be  present;  it  is,  on  the 
whole,  most  frequently  wanting.  I  have  seen  it,  however,  intense 
when  the  cancerous  growth  presses  on  the  bile-ducts.  There  are 
cases  in  which  all  these  symptoms  are  perceived  ;  while  in  others 
only  some  occur,  and  in  others,  again,  even  these  few  may  not  be 
well  defined.  Indeed,  when  we  consider  the  amount  of  deposit 
which  is  generally  present ;  when  we  regard  its  character ;  when  we 
take  into  account  the  necessarily  impaired  function  of  one  of  the 
most  important  glands  in  the  body ;  when  we  reflect  upon  the 
pressure  which    the    enlarged    organ    must  occasion, — it  is  truly 

*  Lectures  on  Diseases  of  the  Liver,  2d  edit. 


576  MEDICAL   DIAGNOSIS. 

astonishing  that  often  so  little  dropsy,  so  little  jaundice,  so  little 
pain,  so  little  constitutional  disturbance  is  produced  by  the  disease. 

Yet  in  point  of  diagnosis  we  can  generally  discern  the  malady 
by  the  combination  of  the  symptoms  and  signs  indicated.  It  is 
only  at  an  early  stage  of  the  disease,  or  when  the  liver  is  not 
enlarged,  that  we  are  apt  to  be  in  doubt.  Under  the  former  cir- 
cumstance, a  swelling  in  the  hepatic  region,  pain  upon  pressure, 
associated  with  retching,  with  nausea  and  vomiting,  and  with  fail- 
ing health  and  strength,  occurring  in  a  person  above  forty  years 
of  age,  may  well  excite  our  suspicion.  But,  unless  there  be  a  his- 
tory of  cancer  in  the  family  or  a  cancer  in  some  other  part  of  the 
body,  we  cannot  be  certain  that  the  beginning  swelling  in  the  right 
hypochondrium  is  malignant.  When  the  liver  is  the  seat  of  cancer, 
but  is  not  increased  in  size,  the  recognition  of  the  malady  is  next 
to  impossible.  In  these  obscure  cases,  the  persistent  tenderness  in 
the  hepatic  region,  accompanying  the  evidences  of  disturbed  func- 
tion of  the  liver,  ascites,  anaemia,  and  a  cachectic  appearance,  are 
the  signs  most  trustworthy  and  most  likely  to  lead  to  a  correct  con- 
clusion. In  any  instance,  jaundice  coming  on  in  a  person  over 
forty  years  of  age,  lasting  for  months,  and  associated  with  gastric 
disease  and  failing  health,  must,  in  the  absence  of  a  history  of  gout 
or  of  syphilis,  be  looked  upon  as  pointing  to  hepatic  cancer.  Again, 
we  must  remember  that  loss  of  flesh  and  of  strength  not  unfre- 
quently  precedes  jaundice  and  pain,  in  fact,  all  signs  of  disorder 
of  the  affected  organ. 

But  let  us  pass  in  review  the  complaints  with  which  well-marked 
cancer  of  the  liver  may  be  confounded.  Omitting  here,  because 
elsewhere  discussed,  hydatids,  abscess  of  the  liver,  and  cirrhosis, 
they  are : 

Waxy  Liver;  Fatty  Liver;  Chronic  Congestion; 
Acute  Congestion  ;  Acute  Hepatitis  ;  Catarrhal  Jaun- 
dice; 

Syphilitic  Liver; 

Affections  of  the  Gall-bladder; 

Cancer  of  the  Stomach; 

Cancer  of  the  Omentum; 

Enlargement  of  the  Right  Kidney. 

Waxy  Liver  ;  Fatty  Liver ;  Chronic  Congestion. — A  waxy  liver 


DISEASES    OF    THE    LIVER.  577 

presents  often  as  much  increase  in  size  as  cancer ;  moreover,  like 
cancer,  it  is  associated  with  evident  signs  of  cachexia.  The  main 
points  of  distinction  are  the  smooth  feel  and  uniform  increase  of 
the  liver  in  waxy  disease,  its  painlessness  and  slow  progress,  its 
combination  with  enlargement  of  the  spleen  and  albuminous  urine, 
and  the  history  of  the  case  pointing  to  constitutional  syphilis  or 
to  diseases  of  the  bones,  or  long-continued  suppuration, — in  fact, 
to  the  causes  which  generally  lie  at  the  root  of  a  waxy  or  larda- 
ceous  state  of  organs.  In  the  differentiation  of  cases  of  infiltrated 
cancer  without  distinct  nodules,  the  physical  exploration  does  not 
aid  us,  and  we  have  to  lay  stress  on  the  other  points. 

A  fatty  liver  is  easier  to  discriminate  from  hepatic  cancer.  The 
occurrence  of  the  non-malignant  malady  in  consumptives  or  in 
drunkards,  and  the  total  absence  of  pain, — in  truth,  of  any  decided 
indications  of  hepatic  disease,  except  increased  size  of  the  organ, — 
enable  us  to  distinguish  between  the  two  affections  with  certainty. 
The  slighter  signs  of  disturbance,  both  constitutional  and  local,  the 
dissimilar  history,  and  the  uniform  enlargement  of  the  liver  sepa- 
rate chronic  congestion  from  cancer.  As  a  mark  of  distinction, 
too,  of  the  cancerous  from  all  of  these  non-malignant  disorders, 
Virchow  lays  stress  on  the  existence  of  swollen  jugular  glands; 
and  a  small  cancerous  induration  in  the  abdominal  walls,  around 
the  umbilicus,  also  not  infrequently  aids  the  diagnosis. 

Acute  Congestion;  Acute  Hepatitis;  Catarrhal  Jaundice. — It  is 
rarely  indeed  that  these  ailments  are  confounded  with  cancer  of  the 
liver,  because  the  history  and  the  course  the  latter  malady  takes 
are  so  dissimilar  to  those  of  an  acute  hepatic  disorder.  Yet 
there  are  cases  in  which  the  malignant  disease  is  either  developed 
with  great  rapidity,  thus  simulating  an  ordinary  acute  affection, 
or  has  lain  dormant  and  passed  unnoticed  until  it  begins  suddenly 
to  increase.  Under  such  circumstances,  even,  we  may  be  able  to 
recognize  the  malignant  complaint,  if  its  physical  phenomena  be 
well  defined ;  but  if  these  be  not  clearly  marked,  the  diagnosis 
becomes  one  of  great  difficulty. 

To  cite  a  case  in  illustration : 

A  married  woman,  twenty-five  years  of  age,  was  admitted  into 
the  Philadelphia  Hospital  on  January  14th,  1862,  with  jaundice 
and  slight  fever.  She  stated  that  she  had  been  in  excellent  health 
until  about  two  weeks  before,  when  she  caught  cold  by  sleeping 

37 


578  MEDICAL   DIAGNOSIS. 

in  a  clamp  apartment.  Her  appetite  and  digestion  had  been  good 
previous  to  her  present  illness,  and  she  had  been  fully  able  to 
perform  her  household  work.  Since  she  was  taken  sick  she  had 
noticed  a  feeling  of  weight  in  the  region  of  the  stomach  and  liver. 
When  examined,  rales  indicative  of  bronchitis  were  found  in  the 
chest,  and  the  impulse  of  the  heart  was  feeble.  The  hepatic  per- 
cussion dulness  was  observed  to  be  increased  in  extent,  especially 
that  of  the  left  lobe ;  but  the  outline  of  the  organ  appeared  regu- 
lar and  even.  Tenderness  at  the  lower  portion  of  the  abdomen, 
but  more  particularly  in  the  epigastrium  and  right  hypochon- 
drium,  was  also  noted.  There  was  nausea,  but  no  vomiting;  the 
tongue  was  clean  ;  the  evacuations  were  discolored. 

Now,  here  was  certainly  a  patient  presenting  none  of  the  signs 
of  hepatic  cancer,  except,  perhaps,  the  tenderness  over  the  en- 
larged gland.  Yet  at  the  autopsy,  which  was  made  within  a  week 
after  her  reception  into  the  hospital,  and  therefore  not  three  weeks 
from  the  apparent  beginning  of  the  complaint,  whitish  nodular 
spots,  evidently  cancerous,  and  many  of  them  soft,  were  found  in 
the  substance  of  the  liver,  but  not  at  its  edges,  nor  forming  any- 
where distinct  protuberances  which  could  have  been  detected 
during  life,  and  which,  had  they  existed  and  been  discerned, 
might,  notwithstanding  the  history  of  the  case,  have  furnished  a 
clue  to  the  cause  of  the  tenderness  and  of  the  hepatic  enlargement. 

To  the  similarity  of  certain  cases  of  protracted  catarrhal  jaun- 
dice in  elderly  persons,  presenting  emaciation,  with  nausea,  retch- 
ing, and  vomiting,  we  have  above  alluded.  The  physical  signs 
of  the  enlargement  of  the  liver  may  or  may  not  assist  us,  accord- 
ing to  their  character. 

Syphilitic  Liver. — As  a  consequence  of  constitutional  syphilis, 
the  liver  may  at  times  exhibit  cicatrices  on  its  surface,  and  scattered 
nodules,  consisting  of  connective  tissue,  and  extending  into  the 
parenchyma.  This  conditiou  is  styled  syphilitic  inflammation  of 
the  liver,  or  the  syphilitic  liver.  The  organ  becomes  uneven  from 
the  contraction  of  the  cicatrized  parts,  and  is  apt  to  be  somewhat 
increased  in  size,  from  coexisting  waxy  degeneration  or  interstitial 
hepatitis.  The  patient  has  a  pale,  cachectic  look,  but  is  not  jaun- 
diced,* except  from  a  temporary  catarrh  of  the  bile-ducts,  produced 

*  No  jaundice  is  mentioned  in  the  cases  of  Dittrich,  Prag.  Vierteljahrschr., 


DISEASES    OF    THE    LIVEE.  579 

by  the  syphilitic  poison ;  nor  is  dropsy  present,  unless  there  be  at 
the  same  time  an  affection  of  the  kidneys  or  enlargement  of  the 
spleen.  But  the  most  important  elements  in  the  diagnosis  are  the 
age  of  the  patient,  the  history  of  the  case,  and  the  detection  of 
syphilitic  cicatrices  iu  the  throat.  When  contrasted  with  cancer, 
we  find,  besides  these  points,  the  chief  distinctive  marks  to  be : 
the  much  more  usual  absence  of  jaundice  and  of  dropsy,  the  not 
uncommon  increase  in  size  of  the  spleen,  the  want  of  local  hepatic 
tenderness, — unless  this  be  due  to  passing  attacks  of  perihepatitis, 
— and  the  smaller  size  and  softer  feel  of  the  nodules. 

Affections  of  the  Gall-bladder. — Dilatation  and  cancer  of  the 
gall-bladder  are  both  very  liable  to  be  mistaken  for  cancer  of  the 
liver.  The  former  affection  may  result  from  occlusion  of  the  he- 
patic and  common  bile-ducts,  produced  by  pressure  of  surrounding 
tumors  or  by  an  impaction  of  gall-stones;  or  it  may  be  owing  to 
the  distention  of  the  bladder  with  an  albuminous  fluid, — the  so- 
called  dropsy  of  the  gall-bladder.  Now,  in  either  instance  the 
bladder  may  attain  an  enormous  volume,  and  give  rise  to  a 
marked  tumor  at  the  lower  margin  of  the  liver.  The  promi- 
nence is  apt  to  be  rounded  or  pear-shaped,  and,  except  in  those 
cases  in  which  the  occlusion  is  in  the  cystic  duct  or  at  the  neck  of 
the  gall-bladder,  the  impediment  to  the  flow  of  bile  is  accompanied 
by  intense  jaundice  and  by  decided  hepatic  swelling.  Hence,  in 
the  deep  hue  of  the  skin,  the  uniform  enlargement  of  the  liver, 
the  peculiar  contour  of  the  prominence,  the  absence  of  ascites,  the 
paroxysms  of  pain  preceding,  not  following,  as  in  cancer  of  the 
liver,  the  other  marked  symptoms,  and  the  history  of  the  case, 
which  not  unfrequently  points  to  repeated  attacks  of  colic  from 
the  passage  of  gall-stones,  we  find  the  clue  which  permits  us  to 
determine  that  we  are  not  dealing  with  hepatic  cancer. 

Cancer  of  the  gall-bladder  is  scarcely  ever  met  with  in  young 
persons,  and  is,  as, a  rule,  associated  with  cancerous  formations  in 
the  liver  or  in  other  organs.  It  is  difficult  to  make  out  a  certain 
diagnosis  of  the  affection,  for  it  presents  a  strong  likeness  both  to 
cancer  of  the  pyloric  extremity  of  the  stomach  and  to  cancer  of 

Bd.  vi.  and  vii. ;  of  Gubler,  Memoires  de  la  Soeiete  de  Biologie,  tome  iv.  ; 
of  Bamberger,  Krankbeiten  der  Leber,  in  Yircbow,  Pathologie,  etc.  ;  or 
of  Moxon,  in  Guy's  Hospital  Beports,  1867 :  in  the  cases  of  Aturcbison, 
Diseases  of  tbe  Liver,  2d  edit.,  1877,  it  was  a  passing  or  absent  symptom. 


580  MEDICAL    DIAGNOSIS. 

the  liver.  From  the  latter  it  is  undistinguishable,  unless  the 
situation  and  form  of  the  tumor  be  such  that  we  can  clearly 
recognize  it  as  belonging  to  the  gall-bladder.  Sometimes  it  is 
preceded  by  a  history  of  gall-stones.*  Jaundice,  as  in  cancer  of 
the  liver,  may  be  absent  or  present :  in  five  cases  reported  by 
Bambergerf  it  was  found  in  all,  and  was  even  intense.  Frerichs, 
on  the  other  hand,  states  that  in  most  instances  it  is  wanting. 
The  signs  of  the  cancerous  cachexia  are  always  strongly  marked; 
perhaps,  as  a  rule,  more  strongly  than  in  hepatic  cancer. 

Gall-stones  occasionally  accumulate  in  the  gall-bladder  in  such 
numbers  as  to  give  rise  to  a  hard,  even  nodulated  swelling,  which 
may  be  mistaken  for  cancer.  But  the  tumor  is  generally  movable, 
is  not  painful  on  pressure,  and  does  not  alter  in  size,  or  does  so 
but  slowly.  Sometimes  the  patient  complains  of  the  feeling  of 
a  weight  rolling  from  side  to  side  when  he  turns  in  bed,  and  on 
palpation  a  crackling  sound  is  produced,  which  is  readily  dis- 
cerned with  the  stethoscope.  Generally  we  obtain  a  history  of 
bilious  colic.  There  may  or  may  not  be  jaundice;  there  is  an 
absence  of  the  cachectic  symptoms  of  cancer. 

Cancer  of  the  Stomach. — This  is  discriminated  from  cancer  of 
the  liver  by  the  far  more  constant  vomiting,  by  the  dark  appear- 
ance of  the  ejected  matter,  by  the  more  obvious  symptoms  of  indi- 
gestion, the  persistent  pain  in  the  stomach,  or  the  pain  radiating 
from  there  to  either  hypochondrium.  Moreover,  the  seat  of  the 
tumor  is  different;  it  is  epigastric,  or  extending  downward,  but 
not  often  passing  into  the  right  hypochondrium,  and  it  shows 
on  percussion  a  very  different  contour  from  an  enlarged  liver. 
Yet  there  are  cases  in  which  we  are  kept  in  doubt;  especially 
those  in  which  the  left  lobe  of  the  liver  is  chiefly  affected  with  the 
cancerous  malady  and  presses  upon  the  stomach,  inducing  perhaps 
— and  thus  making  the  likeness  still  closer — obstinate  vomiting. 
The  only  traits  of  distinction  are  then  found  in  the  presence  or 
absence  of  the  signs  of  marked  derangement  of  the  functions  of 
the  liver. 

Cancer  of  the  Omentum. — The  absence  of  jaundice,  and  the  un- 
altered appearance  of  the  stools,  are  here,  too,  of  great  value  in 

*  Murchison,  op. 

j  Krankheiten  des  Digestions-Apparates. 


DISEASES    OF    THE    LIVER.  581 

indicating  that  a  tumor  near  or  joining  the  left  lobe  of  the  liver 
is  not  due  to  cancer  of  that  viscus.  Moreover,  the  boundaries  of 
the  morbid  mass  are  different  from  those  of  a  diseased  liver.  But 
we  cannot  always  trust  to  this.  Cancerous  tumors  of  the  lesser 
omentum  may  so  surround  the  liver,  and  correspond  so  closely  to 
the  regular  form  produced  by  hepatic  cancer,  that  the  two  mala- 
dies cannot  be  distinguished;  at  least  not  by  the  local  signs. 
Again,  a  loop  of  intestine  may  be  thrust  across  the  enlarged  liver 
at  a  point  corresponding  to  the  usual  limit  of  the  percussion  dul- 
ness  of  its  left  lobe,  thus  dividing  the  most  prominent  nodules 
from  the  greater  portion  of  the  viscus,  and  making  it  appear  as 
if  the  tumor  were  to  the  left  of,  and  below,  the  stomach,  and 
belonged,  therefore,  probably  to  the  omentum.*  In  such  cases 
we  have  to  depend  entirely  upon  the  signs  of  disturbed  liver 
function. 

Enlargement  of  the  Right  Kidney. — A.  tumor  formed  by  an  en- 
largement of  the  kidney  does  not  present  the  same  outline  of  per- 
cussion dulness  as  a  cancerous  liver.  The  dulness  is,  moreover, 
bounded  by  the  tympanitic  sound  of  the  intestine,  and  is  not 
lowered  by  a  deep  inspiration ;  and  the  signs  of  disturbed  function 
of  the  kidney,  and  an  examination  of  the  urine,  will  generally 
materially  assist  the  diagnosis.  Still,  cases  may  occasionally  hap- 
pen in  which,  owing  to  a  peculiar  shape  of  the  diseased  kidney 
and  to  the  obscurity  of  the  symptoms,  an  error  in  diagnosis  can 
scarcely  be  avoided. f  The  difficulty  in  discrimination  is  height- 
ened by  the  circumstance  that  most  cases  of  morbid  growth  of 
the  kidney,  at  least  of  one-sided  growth  sufficient  to  give  rise  to 
a  palpable  tumor,  are  cancerous,  and  are  therefore,  as  far  as  the 
manifestations  of  a  cachexia  go,  similar  to  cancer  of  the  liver. 

Finally,  in  reviewing  the  diagnosis  of  cancer  of  the  liver,  we 
must  inquire  whether  other  than  cancerous  growths,  such  as 
spindle-cell  sarcoma,  myxoma,  epithelioma,  cysto-sarcoma,  lymph- 
adenoma,  can  be  distinguished  from  true  cancer.  They  may  pro- 
duce identical  physical  signs  and  symptoms ;  indeed,  a  distinction 

*  See  case,  Proceedings  Pathological  Society  of  Philada.,  vol.  i.  p.  275. 

f  Vidal  (Bulletin  de  la  Societe  Med.  des  Hopit.,  1874)  cites  errors  in  diag- 
nosis between  tumors  of  the  kidneys,  especially  hydronephrosis,  and  diseases 
of  the  liver  attended  with  enlargement,  like  abscess  or  cancer,  made  by  such 
masters  in  our  art  as  Velpeau,  Nelaton,  Gosselin. 


582  MEDICAL    DIAGNOSIS. 

is  with  our  present  knowledge  impossible,  unless  the  history  of 
the  case  enable  us  to  make  it.  Much  the  same  may  be  said  of 
that  rare  disease,  tubercular  formations  in  the  liver. 

Hydatids  of  the  Liver. — The  development  of  one  or  of 
several  cysts  in  the  liver,  containing  within  them  echinococci,  is 
not,  as  a  rule,  a  disorder  which  occasions  any  serious  disturbance 
of  the  general  health.  Nor  do  the  hydatids  usually  give  rise  to 
either  jaundice,  dropsy,  or  any  marked  signs  of  gastric  or  of  in- 
testinal irritation,  or  to  fever,  or  to  local  pain.  Their  most  con- 
stant manifestations  are  a  decided  increase  of  the  size  of  the  liver, 
and  the  presence  of  elastic  tumors  discernible  in  the  hepatic  region. 
In  some  instances  xanthelasma  has  been  noticed.*  This  singu- 
lar disorder  of  the  skin,  however,  is  not  peculiar  to  hydatids, 
but  has  been  observed  in  connection  with  other  forms  of  hepatic 
enlargement  associated  with  chronic  jaundice. 

The  growth  of  the  hydatid  is  generally  very  slow,  and  usually 
in  one  direction  only, — upward,  downward,  laterally.  Very  com- 
monly the  hydatid  tumor  grows  from  the  right  lobe.  In  most 
cases  it  attains  considerable  dimensions,  and  the  liver  may  be 
found  to  encroach  upon  the  lung  as  far  as  the  second  intercostal 
space,  or  to  extend  far  down  into  the  abdominal  cavity.  On  per- 
cussion, the  line  of  dulness  either  of  the  upper  or  of  the  lower 
boundary  of  the  viscus,  or  of  both,  is  perceived  to  be  very  irreg- 
ular, and  occasionally  on  striking  a  series  of  abrupt  blows  on  the 
pleximeter,  or  on  the  fingers  of  the  left  hand  used  as  such,  we 
discern  a  peculiar  vibration,  similar  to  the  sensation  perceived  on 
striking  a  mass  of  jelly,  to  which  Piorry  was  the  first  to  call  atten- 
tion, and  which  is  very  significant  of  the  existence  of  the  cyst. 
Owing  to  the  pressure  the  increasing  tumor  may  exert  on  ad- 
jacent structures,  we  observe  in  some  cases  dry  cough  ;  palpitation 
and  displacement  of  the  heart;  vomiting, — possibly  jaundice  and 
ascites. 

Hydatids  ordinarily  last  for  years.  The  echinococci  may  die, 
the  sac  become  much  reduced  in  size,  or  obliterated,  and  recovery 
take  place;  or  the  cyst  may  discharge  its  contents  through  the 
stomach  and  intestines,  through  the  bronchial  tubes,  or  through 
the  walls  of  the  abdomen,  and  the  patient  then  gets  well.     But 

*  Duckworth,  St.  Bartholomew's  Hospital  Heports,  vol.  x.,  1874. 


DISEASES    OF    THE    LIVER.  583 

so  favorable  a  termination  cannot  be  counted  upon.  A  fatal  issue 
may  at  any  time  ensue  by  the  hydatid  tumor  bursting  into  the 
pleura  or  the  pericardium  or  the  peritoneum  and  leading  to  vio- 
lent inflammation,  or  by  inflammation  and  suppuration  occurring 
in  the  sac,  or  in  the  tissues  immediately  surrounding  it.  Even 
when  the  hydatids  are  discharged  through  the  stomach,  intestines, 
bronchial  tubes,  or  abdominal  parietes,  recovery  is  apt  to  be  slow; 
nor  is  it,  indeed,  unusual  to  find  the  patient's  strength  giving  way 
before  the  contents  of  the  sac  have  been  entirely  voided  and  it 
has  closed. 

In  some  countries  hydatids  are  much  more  frequent  than  in 
others.  In  Iceland  these  growths  developed  from  the  eggs  of  a 
tapeworm  are  so  common  that  they  cause  one-seventh  of  the 
human  mortality. 

Now,  in  point  of  diagnosis,  it  is  not  generally  difficult  to  detect 
the  presence  of  hydatids.  It  is  true  that  when  these  are  small  or 
deep-seated  it  may  be  impossible  to  discern  them.  But  a  large 
and  superficially  seated  hydatid  tumor  can  usually  be  distin- 
guished, and  can  be  separated  in  most  cases  from  the  maladies  to 
which  it  bears  a  resemblance. 

It  differs  from  an  abscess  of  the  liver  by  the  want  of  that 
febrile  action,  pain,  and  great  constitutional  disturbance  to  which 
the  formation  of  an  abscess  is  so  prone  to  give  rise;  indeed,  the 
latent  character  of  the  hydatid  tumor  becomes  of  much  importance; 
its  slow  growth,  too,  is  very  significant,  much  more  so  than  the 
physical  characteristics,  which  are  here  not  to  be  trusted  to.  When, 
as  sometimes  happens,  a  hydatid  tumor  inflames  and  suppurates, 
we  have  nothing  to  guide  us  in  the  differential  diagnosis  but  the 
history  of  the  case  previous  to  the  development  of  the  urgent 
symptoms.  From  cancer  of  the  liver  we  distinguish  hydatids  by 
the  absence  of  evident  cachexia,  of  local  tenderness,  and  of  the 
unevenness  of  the  surface  which  the  small,  hard  cancerous  tumors 
projecting  from  it  occasion.  On  the  other  hand,  we  have  in 
hydatid  tumor  the  sensation  on  palpation  of  elasticity  or  fluctu- 
ation. Under  rare  circumstances  this  may  happen  in  medullary 
cancer,  and  the  rapid  growth  of  the  latter  and  the  cachectic  symp- 
toms would  determine  the  diagnosis.  A  distended  gall-bladder 
may,  like  hydatid  tumor,  be  free  from  pain  on  pressure,  but, 
unlike  this,  it  is  preceded  by  attacks  of  colic,  is  generally  accom- 


584  MEDICAL    DIAGNOSIS. 

panied  by  deep  jaundice,  and   its  situation  corresponds  to  the 
normal  seat  of  the  gall-bladder. 

An  aneurism  of  the  aorta  differs  from  hydatids  in  the  severe — 
for  the  most  part  neuralgic — pain  the  patient  suffers,  so  utterly 
dissimilar  to  the  absence  of  pain  or  to  the  mere  feeling  of  tension 
and  weight  of  an  hydatid  swelling.  Then  the  pulsation  and  the 
other  physical  signs  aid  us.  In  aneurism  of  the  hepatic  artery, 
which  may  also  present  a  smooth,  throbbing  tumor,  we  are  apt  to 
have  deep  jaundice  from  compression  of  the  biliary  ducts. 

Pleuritic  effusions  have  many  features  in  common  with  those 
cases  of  hydatids  of  the  liver  in  which  the  growing  tumor  extends 
upward  into  the  chest.  All  the  physical  signs  of  a  large  effusion 
may  be  present,  even  the  dilatation  of  the  thorax  and  a  sense  of 
fluctuation  in  the  intercostal  spaces.  But  the  absence  of  constitu- 
tional symptoms,  the  irregular  outline  of  the  dulness  on  percus- 
sion of  the  hydatid  cyst,  the  great  displacement- of  the  heart,  and 
the  decided  lowering  of  the  upper  margin  of  dulness  upon  deep 
inspiration,  enable  us  commonly  to  detect  the  real  nature  of  the 
disease.  When  the  cyst  has  opened  into  the  lung  and  the  hydatids 
are  being  expectorated  through  the  air-passages,  the  harassing 
cough,  the  copious  sputum,  and  the  inflammation  of  the  pulmo- 
nary tissue  which  is  apt  to  be  occasioned,  may  cause  the  affection 
to  be  mistaken  for  pulmonary  abscess  or  phthisis.  The  surest 
marks  of  distinction  are  furnished  by  the  changed  form  of  the 
lower  part  of  the  thorax,  and  by  finding  bile  and  the  hooks  of  the 
echinococci  in  the  sputum. 

Renal  enlargements,  such  as  cysts,  hydronephrosis,  cancer,  are 
discriminated  from  hydatid  cysts  of  the  liver  by  the  same  physical 
signs  by  which  we  found  them  to  be  distinguished  from  cancer 
of  the  liver, — chiefly  by  the  renal  tumor  having  the  tympanitic 
sound  of  the  colon  in  front  of  it,  by  not  being  affected  in  position 
by  deep  inspiration,  and  by  the  direction  of  its  growth.  More- 
over, the  history  of  the  case  and  the  examination  of  the  urine  will 
greatly  assist.     . 

Ovarian  cysts,  unlike  hydatids,  grow  from  below  upward,  are 
not  influenced  by  deep  inspiration,  and  produce  enlargements 
greatest  below  and  not  above  the  umbilicus;  then  they  have  a 
different  outline  on  percussion  from  hydatid  liver. 

But,  though  we  may  thus  generally  distinguish  hydatids  of  the 


DISEASES    OF    THE    LIVER.  585 

liver  from  the  maladies  which  have  similar  symptoms,  there  are 
unquestionably  cases  in  which  it  is  extremely  difficult  to  arrive  at 
a  satisfactory  conclusion.  Under  these  circumstances,  an  explora- 
tory examination  with  a  grooved  needle  or  a  very  fine  trocar  has 
been  recommended.  But  this  proceeding  is  not  wholly  free  from 
danger  unless  the  swelling  be  prominent  and  superficial ;  and  an 
aspirator  would  under  any  circumstances  be  preferable.  We  may 
at  times  detect  shreds  of  striated  hydatid  membrane,  and  portions 
of  echinococci.  Besides,  the  character  of  the  fluid  drawn  off  will 
assist  us  materially  in  diagnosis.  It  is  as  clear  and  colorless  as 
water,  has  a  specific  gravity  of  1007  to  1011,  and  contains  not  a 
trace  of  albumen  or  of  urea,  but  large  quantities  of  chloride  of 
sodium.  No  other  fluid  in  the  human  body,  whether  in  health  or 
in  disease,  presents  these  peculiarities.* 

Occasionally  portions  of  the  liver  are  transformed  into  a  mass 
consisting  of  connective-tissue  stroma  and  numerous  large  and 
small  cells  filled  with  a  gelatinous  substance.  The  disorder  looks 
like  alveolar  carcinoma,  but  it  is  really  multilocular  hydatids  or 
echinococcus  tumors.  The  centre  of  the  mass  suppurates,  but 
even  this  does  not  diminish  the  great  resistance  of  the  hepatic 
tumor;  nor  is  fluctuation,  save  in  the  rarest  instances,  perceptible. 
The  liver  may  retain  its  normal  shape,  or  elevations  may  be  per- 
ceptible, such  as  we  observe  in  carcinoma  and  syphiloma  of  the 
organ  :  indeed,  the  affection  is  not  to  be  distinguished  with  any 
certainty  from  either,  except  it  be  by  the  history  and  the  attend- 
ing constitutional  symptoms.  No  jaundice  usually  accompanies 
the  hard  hepatic  swelling ;  but  in  cases  in  which  the  bile-ducts  are 
obstructed  we  meet  with  jaundice  without  dyspeptic  symptoms  or 
previous  paroxysms  of  pain,  and  usually  without  enlargement  of 
the  gall-bladder.  In  cases  with  icterus,  unlike  what  we  find  in 
syphilis  or  in  cancer,  there  is  complete  discoloration  of  the  faeces,  f 

Let  us  now,  in  concluding  the  review  of  the  hepatic  maladies 
which  are  attended  with  decided  increase  of  the  size  of  the  organ, 
briefly  contrast  their  most  important  manifestations.  We  have 
found  that,  as  regards  the  enlargement,  they  differ  materially. 

*  Murchison,  Lancet,  Nov.  1865;  also,  Lectures  on  Diseases  of  the  Liver, 
2d  edit.,  p.  61. 

f  See  the  cases  of  Friedreich  and  of  Niemeyer,  referred  to  in  his  Practice 
of  Medicine. 


586  MEDICAL    DIAGNOSIS. 

Simple  congestion,  chronic  inflammation,  fatty  liver,  do  not  attain 
nearly  the  volume  of  cancer,  of  hydatids,  of  abscess,  of  waxy  dis- 
ease of  the  liver.  The  three  affections  first  mentioned  differ, 
moreover,  from  all  of  the  others,  except  the  waxy  liver,  by 
presenting  a  uniform  and  not  an  irregularly-shaped  swelling 
or  an  uneven  outline  of  the  percussion  dulness. 

Concerning  the  symptoms,  we  observe  that,  although  these 
hepatic  disorders  all  agree  in  not  being  in  any  way  characterized 
by  jaundice,  yet  this  sign  is  more  commonly  present  and  more 
distinct  in  some  than  in  others.  In  hydatids,  and  in  the  syphilitic 
liver,  there  is  no  yellow  hue  of  the  skin  or  of  the  conjunctiva;  so, 
too,  as  a  rule,  in  waxy  liver.  In  fatty  liver  and  in  abscess  it  is,  on 
the  whole,  most  frequently  wanting.  The  same  may  perhaps  be 
said  of  cancer,  though  sometimes  there  is  decided  icterus  in  this 
malady.  In  chronic  congestion  and  in  chronic  inflammation  we 
ordinarily  find  jaundice,  though  it  may  be  but  a  slight  yellow  tinge 
of  the  skin  and  eye.  With  reference  to  dropsy,  we  are  not  apt  to 
encounter  it  in  any  of  the  hepatic  affections  under  consideration 
except  cancer,  and  waxy  disease,  when  more  than  the  liver  is 
implicated.  It  is  in  these  two  complaints,  also,  that  the  most 
obvious  signs  of  a  cachexia  are  met  with ;  while  in  abscess  we  find 
fever,  and  perhaps  the  greatest  constitutional  disturbance. 

As  regards  pain,  the  fatty  liver,  hydatids,  simple  hypertrophy, 
and  the  waxy  liver  are  painless;  while,  generally  speaking,  con- 
gestion, catarrhal  inflammation  or  obstruction  of  the  bile-ducts, 
chronic  hepatitis,  intestinal  hepatitis,  hepatic  abscess,  and  cancer, 
are  more  or  less  painful  affections. 

Chronic  Diseases  attended  with  Decreased  Size  of  the  Liver, 
and  with  Abdominal  Dropsy, 
Cirrhosis. — A  liver  reduced*  in  bulk,  very  dense  and  hard, 
exhibiting  granulations  of  various  size  separated  by  bands  of 
fibrous  tissue,  and  surrounded  by  a  thickened  serous  envelope, 
presents  the  morbid  state  known  as  cirrhosis,  or  by  the  familiar 
name  of  hob-nail  liver.  The  bands  that  result  from  the  inflam- 
matory thickening  of  the  areolar  structure  of  the  liver  compress 
the  vessels  and  parenchyma,  destroying  some  of  its  secret! ng-cells. 
The  inflammation  which  leads  to  these  alterations  in  the  fibrous 
tissue  is  generally  developed  from  a  chronic  congestion  consequent 


DISEASES    OF    THE    LIVER.  587 

upon  the  abuse  of  spirituous  liquors.  But  this  cause  does  not  ex- 
plain all  eases  :  in  some,  the  malady  is  connected  with  disease  of 
the  heart;  in  others,  with  constitutional  syphilis ;  in  others,  again, 
it  cannot  be  attributed  to  any  known  agency.  Sometimes  it  is 
combined  with  fatty  or  waxy  degeneration.  Again,  there  may  be 
granular  livers  in  which  the  fibroid  matter  preponderates  and 
which  never  contract, — an  interstitial  hepatitis,  or  hypertrophic 
cirrhosis. 

In  the  first  stage  of  cirrhosis,  the  organ  is  somewhat  increased 
in  size;  then,  as  Glisson's  capsule  thickens  more  and  more,  the 
bulk  becomes  lessened.  It  is,  however,  very  doubtful  whether 
the  stage  of  enlargement  invariably  precedes  that  of  shrinking: 
probably  the  process  of  reduction  constitutes  not  infrequently  the 
first  morbid  change. 

But,  without  entering  into  this  question,  we  may  state  that  there 
are  no  symptoms  by  which  we  can  recognize  the  disease  at  an 
early  period,  for  the  symptoms  at  first  are  the  same  as  those  of 
chronic  congestion, — dull  pain,  perhaps  tenderness  at  the  hypo- 
chondrium  and  pain  referred  to  the  shoulder,  disordered  diges- 
tion, and  a  sallow  or  a  jaundiced  hue  of  the  skin.  !Nor  can  we 
say,  even  after  the  stage  of  contraction  is  fairly  developed,  that 
the  diagnosis  of  the  affection  is  easy,  or  indeed  always  possible. 
It  may  rest  on  no  stronger  grounds  than  finding  in  a  person 
who  is  known  to  be  a  spirit-drinker,  "a  tippler,"  an  intractable 
ascites,  without  any  obvious  cause  to  account  for  the  dropsy. 
The  dropsy,  due  to  the  obstruction  of  the  portal  circulation,  con- 
sists first,  and  throughout  most  strikingly,  of  ascites;  as  it  increases, 
oedema  of  the  legs  may  be  developed  and  passing  albuminuria 
from  pressure  on  the  renal  veins. 

Besides  the  dropsy,  the  other  clinical  features  of  the  malady 
are  not  very  marked.  The  most  significant  signs  consist  in  the 
diminution  of  the  percussion  dulness  in  the  hepatic  region,  and 
the  detection,  by  the  touch,  of  firm,  irregular  granulations  on  the 
margin  and  under  surface  of  the  liver.  But  both  these  signs  are 
very  difficult  to  discern,  on  account  of  the  distention  of  the  abdo- 
men with  fluid,  and  the  displacement  of  the  liver  this  may  occa- 
sion. In  fact,  it  is  often  only  after  the  performance  of  paracen- 
tesis that  the  abdominal  walls,  then  no  longer  tense,  will  permit 
us  to  judge  with  any  accuracy  of  the  shrinking  and  altered  state 


588  MEDICAL    DIAGNOSIS. 

of  the  organ.  This  is  more  especially  true  with  reference  to  pal- 
pation; as  regards  percussion,  it  may  be  possible,  even  when  the 
abdomen  is  still  full  of  dropsical  effusion,  to  detect  the  lessened 
extent  of  the  hepatic  dulness. 

Irrespective  of  these  phenomena,  we  find  at  times  other  mani- 
festations of  disease  which  assist  us  in  the  diagnosis  of  cirrhosis. 
They  are — enlargement  of  the  spleen  ;  dilatation  of  the  veins 
of  the  abdomen;  gastric  and  intestinal  derangements;  haemor- 
rhoids ;  marked  loss  of  flesh  and  strength  ;  jaundice  ;  a  decidedly 
cachectic  appearance,  with  sunken  features ;  and  hemorrhages 
from  the  nose  and  mouth,  or  from  the  stomach,  or  into  in- 
ternal cavities.  The  increase  in  size  of  the  spleen  is,  however,  far 
from  constant,  and  rarely  reaches  a  considerable  extent.  The  dila- 
tation of  the  abdominal  veins  is  not  perceived  until  an  advanced 
stage  of  the  disease,  and  is  sometimes  connected  with  a  peculiar 
vascular  net-work,  stretching  from  the  umbilicus  upward  and 
downward,  and,  as  Sappey*  was  the  first  to  describe,  with  a 
decided  enlargement  of  the  epigastric  and  mammary  veins,  the 
blood  flowing  through  the  former  in  a  reversed  direction  from 
what  it  does  in  health, — namely,  not  toward  the  liver,  but  from  it 
to  the  veins  of  the  abdominal  wall,  and  thence  to  the  vena  cava. 
Other  external  veins  share  in  the  enlargement ;  the  veins  of  the 
legs  may  be  varicose,  and  the  venous  twigs  on  the  cheeks  become 
developed. 

Another  symptom  to  which  I  have  had  my  attention  strongly 
directed  is  the  presence  of  small  amounts  of  sugar  in  the  urine. 
Thus,  in  two  cases  which  I  saw  not  long  since  with  Dr.  Simpson, 
Trommer's  test  readily  detected  the  presence  of  sugar  in  the 
urine.  In  the  one  case  the  secretion  was  scanty ;  in  the  other  it 
was  abundant.  One  had  lasted  for  several  years,  and  was  slowly 
developing;  the  other  had  existed  about  sixteen  months,  and  was 
rapidly  progressing. 

The  gastric  and  intestinal  derangements,  the  result  of  a  con- 
gested or  inflamed  mucous  membrane,  are  rarely  wanting  :  they 
manifest  themselves  by  failing  appetite,  impaired  digestion,  both 
gastric  and  intestinal,  morning  sickness,  flatulency  and  constipa- 
tion, or  the  frequent  voiding  of  pale-colored  stools.     The  jaundice 

*  Bulletin  de  l'Academie  de  Medecine,  tome  xxiv. 


DISEASES    OF    THE    LIVEE.  589 

does  not  often  attain  a  very  high  degree ;  when  it  does  it  has  a 
bad  meaning.  It  shows  itself  usually  in  a  yellowish  tinge  of  the 
skin  and  conjunctiva  ;  but  in  some  cases  even  this  hue  is  absent, 
and  we  find  the  pale  skin  and  pearly  eye  of  anaemia. 

Yet  not  one  of  these  symptoms  is  really  characteristic;  they 
become  so  only  when  viewed  in  connection  with  the  dropsy,  with 
the  local  signs  in  the  hepatic  region,  with  the  history  of  the  case, 
and  with  the  absence  of  any  organic  disease  of  the  stomach  or 
the  intestine,  which  might  explain  them.  Then  the  age  of  the 
patient,  generally  above  thirty-five  years,  and  his  habits,  must  be 
taken  into  account.  The  cirrhosis  of  young  children  is  gen- 
erally due  to  inherited  syphilis.  Gout  seems  to  predispose  to 
the  disease.  Murchison  tells  us  that  the  condition  of  liver  which 
develops  gout  renders  it  liable  to  suffer  from  alcohol. 

Another  form  of  cirrhosis,  by  comparison  rare  it  is  true,  has 
been  alluded  to, — hypertrophic  cirrhosis,  or  "  interstitial  hepatitis," 
or  cirrhotic  enlargement.  Has  it  different  symptoms  or  different 
causation?  No;  it  has  the  same,  and  is  undistinguishable,  except 
by  the  increased  percussion  dulness  it  presents,  and  by  the  signs 
of  enlarged  liver  being  usually  attended  with  more  jaundice  and 
greater  tendency  to  slight  febrile  attacks,  and  to  peritonitis.* 
A  peculiar  mawkish  odor  of  the  breath  has  been  spoken  of  as 
present.f 

But,  with  reference  to  these  symptoms,  there  are  forms  of 
hypertrophic  cirrhosis  with  but  slight  jaundice,  without  ascites  or 
marked  development  of  the  abdominal  subcutaneous  veins,  termi- 
nating in  a  slow  cachexia.  Generally,  however,  the  disease  begins 
with  the  signs  of  congestion,  acute  or  chronic,  with  jaundice,  and 
with  some  pain  in  the  right  hypochondrium,  and  lasts  for  years ; 
at  the  end  there  is  marked  jaundice,  and  the  patient  sinks  into 
a  typhoid  state.  Ascites  may,  as  already  indicated,  be  wanting 
throughout,  or,  as  is  more  usual,  it  comes  on  late  in  the  malady. 
The  disease  is,  in  my  experience,  not  infrequently  complicated 
with  a  fatty  liver,  forming  "  a  fibro-fatty  liver."  As  regards  the 
cirrhotic  state  in  the  markedly  enlarged  liver,  recent  observers 
have  told  us  that  besides  the  increase  of  fibrous  tissue  in  some 


*  Hayem,  Archives  de  Physiologie,  Jan.  1874. 

j-  Duckworth,  St.  Bartholomew's  Hospital  Keports,  1874. 


590  MEDICAL    DIAGNOSIS. 

forms,  both  within  and  without  the  lobules,  the  smallest  biliary- 
ducts  are  much  developed.* 

The  form  of  cirrhosis  just  described,  if  interstitial  hepatitis  be 
a  form  and  not  a  separate  disease,  has  always  its  origin  in  con- 
gestion of  the  organ.  But,  not  to  discuss  it  further,  let  us  look  at 
the  distinction  between  ordinary  cirrhosis  and  some  of  the  mala- 
dies which  resemble  it;  and  first  let  us  compare  its  traits  with 
those  of  other  hepatic  affections.  From  diseases  of  the  liver 
attended  with  enlargement,  such  as  waxy  liver,  fatty  liver,  and 
chronic  congestion,  fully-developed  cirrhosis  is  discriminated  by 
the  presence  of  ascites  and  the  other  signs  of  seriously- obstructed 
portal  circulation,  by  the  diminished,  certainly  not  augmented,  size 
of  the  organ,  and  by  the  different  history  of  the  disorder.  From 
hydatids  of  the  liver  we  diagnosticate  cirrhosis  by  the  irregularity 
of  outline  of  the  enlarged  liver  in  the  former  complaint,  by  the 
sense  of  fluctuation,  and  by  the  comparatively  unimpaired  general 
nutrition  of  the  body.  Cancer  of  the  liver  is  unlike  cirrhosis  in 
the  distinctness  and  size  of  the  protuberances,  in  the  obvious  he- 
patic enlargement,  in  the  less  marked  or  absent  ascites,  and  in  the 
normal  size  of  the  spleen.  But  when  a  cirrhosed  liver  is  associ- 
ated with  syphilitic  nodules,  or  when  its  volume  is  augmented  by 
waxy  infiltration,  the  discrimination  from  cancer  becomes  a  matter 
of  extreme  difficulty ;  indeed,  it  may  be  impossible  to  avoid  erro- 
neous conclusions.  Hypertrophic  cirrhosis  may  also  be  very  diffi- 
cult to  distinguish  from  cancer,  except  by  the  history  of  alcoholic 
dyspepsia  and  the  enlargement  of  the  veins,  and,  though  large  and 
nodulated,  the  liver  is  rarely  so  tender. 

We  shall  now  consider  and  compare  the  clinical  traits  of  some 
diseases  of  the  liver  producing,  like  cirrhosis,  atrophy  of  the  organ. 

As  the  result  of  repeated  attacks  of  perihepatitis,  we  find  great 
thickening  of  the  capsule,  with  fibrous  bands  passing  into  the 
interior  of  the  organ,  and  some  atrophy.  This  condition,  de- 
scribed as  simple  induration  of  the  liver,  is  met  with  chiefly  in  con- 
nection with  constitutional  syphilis,  though  it  is  also  seen  following 
a  right-sided  pleurisy  and  diseases  of  parts  contiguous  to  the  liver, 
producing  inflammation  which  spreads  to  it.  The  affection  is  not 
to  be  distinguished   from  true  cirrhosis,  except  by  the  causing 

*  See  an  excellent  review  by  Hanot,  Arch.  Gen.  de  Med.,  Oct.  1877. 


DISEASES    OF    THE    LIVER.  591 

elements,  particularly  by  the  syphilitic  history,  and  by  the  absence 
of  the  habit  of  spirit-drinking;  the  greater  and  more  persistent 
pain  and  tenderness  in  the  hepatic  region  are  of  significance ; 
sometimes  there  is  coexisting  heart  disease. 

In  red  atrophy,  too,  we  have  greatly  diminished  hepatic  dulness 
with  the  symptoms  of  portal  obstruction  ;  it,  too,  is  therefore  un- 
distinguishable  from  cirrhosis  by  the  symptoms  alone,  unless  the 
difference  may  be  thought  to  consist  in  the  doubtful  points  of  far 
less  frequent  or  decided  jaundice  and  in  outbreaks  of  diarrhoea. 
But,  in  reality,  the  only  traits  of  importance  on  which  to  base  a 
diagnosis  are  that  the  dense,  reddish,  homogeneous  liver  occurs  not 
preceded  by  alcoholic  dyspepsia  or  valve  disease,  but  generally 
in  those  with  a  most  marked  history  of  malaria  or  of  dysentery 
or  of  ulceration  of  the  intestine. 

An  inflammation  of  the  portal  vein,  with  coagula  forming  in  it, 
may  occasion  the  same  manifestations  of  deranged  abdominal  cir- 
culation, the  same  or  greater  tumefaction  of  the  spleen  and  decrease 
of  the  liver,  as  cirrhosis.  And  what  complicates  the  diagnosis 
very  much  is,  that  cirrhosis  is  one  of  the  chief  diseases  which  lead 
to  obstruction  of  the  portal  vein.  Indeed,  we  cannot,  under  any 
circumstances,  positively  discriminate  this  affection  from  cirrhosis. 
Still,  we  are  sometimes  enabled  to  distinguish  the  former  disorder 
by  laying  stress  on  the  much  quicker  development  of  the  symp- 
toms, and  by  noting  the  rapidity  with  which  the  ascites  returns 
after  the  performance  of  the  operation  of  paracentesis,  the  copious 
gastric  or  intestinal  hemorrhage,  the  severe  vomiting  and  diarrhoea, 
great  enlargement  of  the  abdominal  veins,  and,  when  not  too  soon 
fatal,  the  marked  emaciation.  Other  causes,  of  course,  than  in- 
flammation of  the  coats  of  the  vein  produce  coagula.  We  may 
have  thrombosis  from  mere  weakness  of  the  circulation,  or  as 
the  result  of  disease  of  the  liver  structure,  or  of  compression  by 
enlarged  cancerous  or  tubercular  glands.  The  clinical  manifesta- 
tions are  the  same  as  those  just  described.  Compression  of  the 
portal  vein  and  of  the  biliary  ducts  in  the  fissures  of  the  liver,  in 
consequence  of  the  inflammation  of  the  areolar  tissues  surround- 
ing them,  may  be  separated  from  cirrhosis  chiefly  by  the  intense 
icterus  and  by  the  complete  discoloration  of  the  stools. 

Of  non-hepatic  affections,  cirrhosis  is  most  liable  to  be  con- 
founded with  chronic  peritonitis ;   a  mistake  rendered  the  more 


592  MEDICAL    DIAGNOSIS. 

likely  because  chronic  congestion  or  even  chronic  inflammation 
of  the  peritoneum  may  exist  as  a  complication  of  cirrhosis.  But, 
even  when  no  such  complication  is  present,  the  diagnosis  may  be 
difficult.  It  rests  chiefly  upon  the  greater  and  more  extended 
tenderness  of  the  abdomen  in  peritonitis,  the  febrile  signs,  the 
absence  of  splenic  enlargement  and  of  dilated  veins,  the  usually 
unchanged,  or  certainly  not  jaundiced,  hue  of  the  skin,  the  asso- 
ciation with  signs  of  disease  in  other  viscera,  especially  of  the 
lungs, — for  chronic  peritonitis  is  generally  tubercular, — and  the 
dissimilar  history  of  the  case. 

Under  rare  circumstances,  cancer  of  the  stomach  may  simulate 
cirrhosis.  I  had  some  years  since  a  case  under  my  charge  at 
the  Pennsylvania  Hospital,  in  which,  with  very  slight  digestive 
symptoms,  and  without  discernible  epigastric  tumor,  considerable 
ascites  and  effusion  into  the  left  pleural  cavity  existed.  Owing 
to  this  effusion,  the  state  of  the  spleen  could  not  be  accurately 
ascertained.  There  was  some  fulness  of  the  abdominal  veins, 
and  the  hepatic  percussion  dulness  did  not  extend  entirely  to  the 
margin  of  the  ribs.  Bile-pigment  was  present  in  the  urine,  the 
bowels  were  loose,  and  progressive  emaciation  ensued.  The  man 
had  been  very  intemperate,  and  his  case  might  certainly  have  been 
selected  as  an  illustration  of  cirrhosis;  yet  at  the  autopsy  the 
liver,  though  small,  rather  hard,  and  deeply  congested,  was  not 
cirrhotic,  and  a  cancer  involving  the  whole  stomach,  except  the 
pylorus,  was  found.* 

Chronic  Atrophy  of  the  Liver. — Although  cirrhosis  is  the 
most  frequent  it  is  not  the  sole  cause  of  dwindling  of  the  liver. 
We  have  just  alluded  to  its  diminution  in  consequence  of  obstruc- 
tion of  the  trunk  of  the  portal  vein,  as  well  as  to  other  causes ;  but 
besides  these  causes  we  find  some,  such  as  a  decrease  of  the  organ 
from  long-continued  closure  of  the  common  duct,  or  its  atrophy 
in  old  age,  or  in  connection  with  grave  disease  of  the  heart  or 
lungs  obstructing  the  circulation  and  causing  long-standing  hy- 
peremia of  the  liver,  or  as  an  accompaniment  of  chronic  disease 
of  the  intestine.  The  first  of  these  morbid  states  is  mainly  dis- 
criminated by  the  deep  jaundice;  the  second,  by  the  absence  of 

*  See,  for  a  fuller  report  of  this  case,  Proceedings  of  the  Pathologica1 
Society,  American  Journal  of  the  Medical  Sciences,  vol.  lii.,  1866. 


ABDOMINAL    ENLARGEMENT.  593 

any  imj)ortant  symptoms  referable  to  the  liver  and  associated 
with  the  diminished  hepatic  dulness;  the  third,  by  the  history  of 
the  case  and  the  physical  signs  of  cardiac  or  pulmonary  difficulty, 
the  more  general  dropsy,  or  at  least  by  the  oedema  of  the  legs 
preceding  the  ascites.  The  fourth  form,  partly  already  mentioned 
under  red  atrophy,  which  it  may  become,  presents  the  phenomena 
of  cirrhosis,  and  cannot  be  distinguished  from  this  unless  the  sur- 
face of  the  liver  can  be  distinctly  felt  through  the  abdominal  walls 
and  ascertained  not  to  be  irregular.  We  may  sometimes  suspect 
the  cause  of  the  shrinking  of  the  organ  from  the  persistent  and 
intractable  diarrhoea  and  disturbance  of  the  stomach.  But,  on 
the  whole,  this  decrease  in  size  of  the  liver  following  gastro-enteric 
inflammation  is  not  frequent :  in  truth,  there  is  no  cause  of  simple 
atrophy  of  the  liver  so  common  as  coagulation  of  blood  in  the 
portal  vein. 


SECTION  IV. 

ABDOMINAL    ENLARGEMENT. 

In  describing  the  causes  of  abdominal  enlargement,  I  shall  view 
them  as  they  occasion  a  general  and  uniform  or  a  more  circum- 
scribed and  partial  swelling. 

General  Abdominal  Enlargement, 

Ascites. — The  collection  of  serous  fluid  in  the  peritoneal  sac 
gives  rise  to  dropsy  of  the  belly,  or  ascites.  This  may  form  part 
of  a  general  dropsy,  and  be  dependent  upon  an  organic  disease  of 
the  kidneys  or  the  thoracic  viscera,  or  the  accumulation  of  liquid 
may  be  confined  to,  or  at  all  events  occupy  principally,  the  abdo- 
men. In  either  case  the  local  signs  are  much  the  same.  They 
are :  enlargement  of  the  belly;  a  dull  sound  on  percussion,  due  to 
the  presence  of  liquid ;  and  the  sense  of  fluctuation  imparted  to 
the  hand  on  one  side  of  the  abdomen  by  a  wave  of  fluid  put  into 
motion  by  a  tap  on  the  other  side. 

As  regards  the  former  of  these  signs,  it  is  uniform  and  pro- 


594  MEDICAL   DIAGNOSIS. 

gressive,  and  is  usually  very  evident, — so  evident  as  frequently 
to  attract  the  patient's  attention  ;  although,  of  course,  when  the 
quantity  of  liquid  is  small,  enlargement  of  the  abdomen  may 
escape  detection.  The  percussion  dulness  is  most  readily  perceived 
at  the  lower  portion  of  the  abdomen,  where  the  fluid  gravitates, 
unless  when  prevented  from  so  doing  by  being  circumscribed  by 
peritoneal  adhesions.  The  bowels  float  usually  to  the  upper  part 
of  the  liquid,  and  at  this  spot  their  tympanitic  resonance  may  be 
distinctly  discerned.  When  the  patient  is  in  the  erect  position, 
the  intestinal  percussion  note  is  commonly  discoverable  in  the  epi- 
gastric and  umbilical  regions.  If  he  be  placed  upon  his  back,  the 
tympanitic  sound  is,  for  the  most  part,  found  to  extend  lower 
than  the  umbilical  region,  while  dulness  will  be  elicited  in  the 
hypogastric  region  and  the  flanks.  If  the  person  affected  with 
ascites  be  placed  upon  his  side,  the  flank  which  is  uppermost  be- 
comes resonant.  This  alteration  of  the  level  of  the  fluid  with 
the  change  of  position  is  thus  a  very  significant  sign,  and  always 
happens  except  when  the  effusion  is  encysted ;  it  is  also,  as  a 
rule,  detected  without  difficulty,  save  where  great  flatulent  dis- 
tention of  the  bowels  or  impaction  of  faeces  accompanies  the 
accumulation  of  liquid. 

Ordinarily,  the  fluctuation  wave  felt  by  the  hand  is  easily  dis- 
cerned. It  is,  however,  obscured  by  thickening  of  the  abdominal 
walls  from  oedema,  or  from  the  accumulation  of  fat  in  the  sub- 
cutaneous tissues;  it  is,  moreover,  indistinct  if  adhesions  circum- 
scribe the  fluid  in  the  peritoneum. 

The  other  symptoms  often  found  in  ascites,  such  as  a  pushing 
upward  of  the  liver,  spleen,  and  stomach,  embarrassed  breathing, 
perhaps  compression  of  the  lungs,  and  digestive  disturbances, 
need  not  be  specially  described,  as  they  present  nothing  character- 
istic. Nor  is  it  necessary  to  insist  upon  the  self-evident  fact  that 
a  diagnosis  of  ascites  is  only  half  the  diagnosis  of  a  case,  and  that 
we  should  in  every  instance  endeavor  to  ascertain  the  cause  of  the 
collection  of  fluid  in  the  peritoneal  sac.  And  we  may  at  once 
proceed  to  consider  the  morbid  states  with  which  dropsy  in  the 
peritoneum  is  liable  to  be  confounded.     They  are  chiefly : 

Ovarian  Dropsy; 

Chronic  Peritonitis  ; 

Distention  of  the  Bladder  : 


abdominal  enlargement.  595 

Gravid  Uterus; 

Chronic  Tympanites. 

Ovarian  Dropsy. — It  is  not  until  an  ovarian  cyst  rises  above 
the  brim  of  the  pelvis  that  it  occasions  a  swelling  marked  enough 
to  be  mistaken  for  abdominal  dropsy.  Supposing  that  it  has  led 
to  considerable  enlargement  of  the  belly,  we  are  yet  able  to  dis- 
criminate between  the  two  disorders  by  attention  to  the  physical 
signs  of  the  history  of  the  case. 

As  regards  the  former,  we  perceive  these  differences :  the  sound 
on  percussion  over  an  ovarian  cyst  is  dull  in  the  umbilical  and 
hypogastric  regions,  while  at  the  sides  the  tympanitic  resonance 
of  the  intestines  may  be  obtained.  Moreover,  when  the  patient 
assumes  different  postures  the  dulness  in  ovarian  dropsy  does  not 
change  its  position  ;  and,  like  all  ovarian  tumors,  the  ovarian 
dropsy  causes  a  projection  in  the  centre  of  the  abdomen,  not  a 
flattening  there  and  a  bulging  of  the  flanks,  as  is  common  in 
ascites.  In  ascites,  vaginal  and  rectal  touch  detect  fluctuation  at 
once,  and  the  uterus  is  normal  in  size,  in  position,  and  in  mobility,- 
sometimes  it  is  prolapsed ;  in  ovarian  dropsy,  fluctuation  is  less 
distinct  and  may  not  be  reached  at  all,  or  may  not  exist  in  case  of 
polycyst,  and  the  uterus  is  generally  displaced  behind  the  cyst. 
Then,  the  fluctuation  from  an  ovarian  cyst  is  rarely  as  perfect  as 
from  a  collection  of  fluid  in  the  peritoneum,  and  is  apt  to  be  very 
unequal  at  different  parts  of  the  distended  abdomen.  When  the 
effused  fluid  is  free  in  the  peritoneal  cavity,  fluctuation  may  be 
perceived  beyond  the  line  of  dulness  as  the  fluid  is  thrown  in 
waves  among  the  intestines ;  but  when  it  is  confined  within  a  cyst, 
fluctuation  cannot  be  perceived  beyond  the  cyst- walls  :  hence  the 
outline  of  the  cyst  as  obtained  by  percussion,  and  that  of  the  area 
within  which  fluctuation  is  perceived,  must  be  the  same.  It  should 
be  remembered,  however,  that  fluctuation  in  an  ovarian  cyst  may 
entirely  escape  detection  on  account  of  the  great  thickness  of  the 
cyst-walls,  or  the  unusual  tenseness  of  the  cyst,  even  though  it  be 
large,  or  on  account  of  the  great  density  of  the  fluid,  or  the  small 
amount  of  fluid  in  each  cyst.  Lastly,  the  pulsations  of  the  aorta 
are  transmitted  by  an  ovarian  tumor  to  the  anterior  surface  of  the 
abdomen,  and  can  be  there  felt  by  the  hand.  Thus  the  physical 
phenomena  of  the  two  maladies  are  very  dissimilar. 

When,  however,  there  is  ascites  complicating  an  ovarian  tumor, 


596  MEDICAL    DIAGNOSIS. 

the  diagnosis  is  very  difficult.  Finding  the  fluctuation  unequal, 
and  an  irregular  outline  of  the  ovarian  growth,  may  aid  us;  but 
a  preliminary  tapping  may  be  necessary  to  arrive  at  an  opinion. 
According  to  Spencer  Wells,*  entire  reliance  cannot  be  placed  on 
the  chemical  character  of  the  fluid,  since  the  rule  that  paralbumen 
is  characteristic  of  ovarian  fluids  and  fibrin  of  serous  fluids  is 
open  to  many  exceptions.  Spencer  AVellsf  accepts  the  presence 
of  the  "granular  cell"  detected  by  the  microscope,  as  shown  by 
Drysdale  and  W.  L.  At  lee,  J  as  characteristic  and  of  great  value 
in  the  diagnosis  of  ovarian  fluid.  This  granular  cell,  as  described 
by  Drysdale,§  is  generally  round,  sometimes  oval,  varies  in  diame- 
ter from  one  five-thousandth  to  one  two-thousandth  of  an  inch,  is 
very  elevated  and  transparent,  is  much  smaller  and  far  less  opaque 
than  the  compound  granular  cell  of  inflammation,  and  contains  a 
number  of  fine  well-defined  granules  which  become  more  distinct 
on  the  addition  of  acetic  acid,  and  nearly  transparent  under  ether, 
while  the  appearance  of  the  cell  is  not  changed.  There  is  no 
nucleus.  In  several  very  doubtful  cases  of  abdominal  tumor  the 
diagnostic  import  of  the  cell  was  well  attested. || 

In  uncomplicated  cases,  the  history  assists  us  greatly  in  reach- 
ing a  correct  diagnosis.  In  ovarian  dropsy,  we  can,  as  a  rule, 
make  out  that  the  distention  of  the  abdomen  has  begun  at  its 
lower  portion,  and  has  gradually  spread  upward,  one  side  being 
very  much  more  prominent  than  the  other,  until  the  abdominal 
enlargement  has  become  considerable  and  the  relative  position  of 
the  umbilicus  is  altered.  Again,  the  constitutional  disturbance 
is  less, — often,  indeed,  the  general  health  is  scarcely  disturbed; 
and  we  do  not  find  those  signs  of  disease  of  the  liver,  heart,  or 
kidneys  which  are  so  apt  to  coexist  with  ascites,  or  that  the 
swelling  is  temporarily  reduced  by  the  use  of  hydragogue  cathar- 
tics and  diuretics,  as  in  the  latter  disease. 

Attention  to  the  history  and  progress  of  the  complaint  is  es- 
pecially valuable  in  the  class  of  cases  in  which  the  physical  signs 
are  modified  by  the  intestines  not  being  able  to  float  to  the  sur- 

*  Di -eases  of  the  Ovaries. 

f  Brit.  Med.  Journ.,  June,  1878.  J  Ovarian  Tumors. 

\  Transactions  of  the  American  Medical  Association,  1873. 
||  See  Transactions  of  the  Pathological  Society  of  Philadelphia,  vol.  vii., 
1^77  :   and  American  Journal  of  Obstetrics,  vol.  xii.,  1879. 


ABDOMINAL    ENLARGEMENT.  597 

face  of  the  fluid  in  the  peritoneal  cavity,  in  consequence  of  adhe- 
sions to  one  another,  or  of  a  diseased  omentum,  or  in  which  the 
fluid  has  been  limited  in  sacs  by  inflammatory  adhesions.  These 
are  cases  in  which  a  peritoneal  inflammation  has  led  to  the  effu- 
sion of  liquid  ■  and  the  history  of  antecedent  peritonitis,  or  of 
peritonitis  in  connection  with  tubercular  disease,  the  pain  and 
tenderness,  the  signs  sometimes  of  a  tubercular  affection  of  the 
peritoneum  and  mesenteric  glands,  and  the  evidences  of  serious  im- 
pairment of  the  whole  system,  will  go  far  toward  elucidating  the 
diagnosis.  On  the  other  hand,  an  ovarian  cyst  may  contain  air, 
either  from  a  communication  with  the  intestine  or  after  tapping 
and  decomposition  of  the  contained  fluid,  and  percussion  would 
then  give  a  clear  note  in  front  and  a  dull  note  below.  Under 
either  of  these  circumstances  physical  signs  alone  could  not  enable 
us  to  make  a  diagnosis,  and  we  should  have  to  seek  further  light 
from  the  history  and  general  condition  of  the  patient. 

Chronic  Peritonitis. — The  effusion  which  forms  in  consequence 
of  inflammation  of  the  peritoneum  is  commonly  spoken  of  as  one 
of  the  forms  of  ascites.  Excluding  the  kind  of  chronic  inflamma- 
tion which  is  due  to  an  attack  of  acute  peritonitis  passing  into  a 
chronic  state,  let  us  inquire  how  cases  of  chronic  peritonitis,  in 
which  the  disease  was  gradual  in  its  development,  can  be  distin- 
guished from  pure  dropsical  effusion. 

Now,  these  cases  of  chronic  peritonitis  are,  with  the  exception 
of  those  infrequent  instances  of  chronic  diffused  peritonitis  of 
latent  origin  which  we  have  already  discussed,  almost  invariably 
associated  with  tubercle  or  with  cancer,  and  only  under  rare  con- 
ditions with  chronic  dysentery  and  dilatation  of  the  colon.  In 
tubercular  peritonitis  the  malady  generally  occurs  in  those  who 
have  at  the  same  time  tubercles  in  the  lungs  or  enlarged  caseous 
glands  ;  and  when  we  find  such  patients  complaining  of  abdomi- 
nal pain  and  uneasiness,  of  soreness  to  the  touch,  of  nausea  and 
vomiting,  of  diarrhoea  alternating  with  constipation,  of  having 
more  or  less  fever,  and  of  losing  flesh  and  strength ;  when  we  dis- 
cover the  tender  abdomen  to  be  tense  and  much  distended,  in  part 
with  liquid,  but  especially  with  wind,  and  sometimes  very  resist- 
ant to  the  touch,  and  exhibiting  on  its  exterior  the  tracings  of  the 
convolutions  of  the  intestines ;  when  in  addition  there  is  oedema 
of  the  lower  limbs,  and  we  find  the  fever  to  be  irregular,  at  times 


598  MEDICAL    DIAGNOSIS. 

high,  at  times  almost  ceasing,  and  a  growing  cachexia;  when  we 
are  able  to  exclude  as  the  cause  of  the  dropsy  disease  of  the  heart, 
disease  of  the  kidneys,  and  cirrhosis  of  the  liver, — we  can  hardly  be 
wrong  in  presuming  the  signs  of  chronic  peritoneal  inflammation 
to  be  owing  to  the  presence  of  tubercular  granulations  or  of  tuber- 
culous disease  of  the  mesenteric  glands.  Even  when  the  signs  of 
disease  of  the  lungs  are  wanting,  or  are  not  well  defined,  we  shall 
generally  be  correct,  if  the  abdominal  symptoms  mentioned  exist, 
in  determining  the  peritoneal  affection  to  be  tubercular.  But  there 
may  be  really  a  peritoneal  strumous  disease  with  very  similar 
symptoms.*  In  both  may  occur  a  strong  tendency  to  inflamma- 
tion of  the  serous  membranes,  as  of  the  pleura.  In  some  instances 
the  tubercular  abdominal  disorder  develops  with  rapidity,  and  the 
disease  has  not  so  much  the  aspect  of  a  chronic  as  of  an  acute  com- 
plaint. The  tumefaction  and  tension  of  the  belly  may  be  so  great 
as  to  simulate  an  abdominal  tumor,  f 

A  cancer  of  the  peritoneum  gives  rise  to  many  of  the  same 
phenomena  as  tuberculous  disease.  But  the  affection  is  far  less 
common,  and  there  is  this  difference:  the  malady  usually  happens 
consecutively  to  an  external  or  an  internal  cancer,  and  scarcely 
ever  save  in  persons  advanced  in  years;  there  is  less  fever,  per- 
haps none;  no  diarrhoea,  or  but  little  diarrhoea,  and  no  profuse 
sweats,  occur;  whereas  pain,  or  at  least  attacks  of  spontaneous 
pain,  are  more  frequent;  the  lymphatic  glands  enlarge;  and,  as 
the  omentum  is  the  most  common  seat  of  the  cancerous  growth, 
we  can  generally  detect  a  tumor  stretching  across  the  upper  por- 
tion of  the  abdomen,  and  extending  perhaps  from  the  epigastrium 
nearly  to  the  pelvis.  The  morbid  mass  is  unequal,  and  usually 
detected  readily,  except  where  separated  by  fluid  from  the  ab- 
dominal parietes.  Hemorrhage  into  the  abdominal  cavity  or  the 
effusion  of  bloody  serum  occurs  here  as  it  does  in  tubercular  peri- 
tonitis. In  primary  cancer  of  the  peritoneum,  or  that  following 
cancer  of  the  retro-peritoneal  glands,  the  diagnosis  is  very  obscure, 
unless  the  tumors  are  marked.  The  cancerous  malady  is  apt  to 
pursue  a  slowly  progressive  course,  lasting  months;  but  it  may 
develop  as  an  acute  miliary  disease. 


*  Cases  of  Handfield  Jones,  Med.  Times  and  Gaz.,  July,  1873. 
f  See  case  in  Liverpool  Hospital  Reports,  18G8. 


ABDOMINAL,    ENLARGEMENT.  599 

Now,  it  is  not  necessary  to  point  out  at  any  length  the  differ- 
ences between  these  forms  of  chronic  peritonitis  and  the  ordinary 
kind  of  dropsy  of  the  peritoneum.  Both  the  local  and  the  general 
symptoms  are  very  dissimilar,  as  will  be  seen  at  once  by  contrast- 
ing the  description  just  given  with  that  of  ascites. 

Distention  of  the  Bladder. — This  may  give  rise  to  a  sense  of  fluc- 
tuation and  to  very  marked  abdominal  enlargement;  so  marked, 
indeed,  that  patients  have  been  tapped,  under  the  supposition  that 
they  were  laboring  under  dropsy  of  the  abdomen.  But  when 
the  bladder  is  so  much  distended  as  to  simulate  ascites,  there  is 
usually  more  or  less  tenderness  on  pressure  over  the  seat  of  the 
obvious  swelling;  which,  moreover,  presents  a  rounded  outline 
of  dulness  on  percussion.  Again,  we  have  the  history  either  of 
retention  or  of  apparent  incontinence  of  urine.*  But,  to  avoid 
all  possible  chance  of  error,  in  any  case  of  doubt  a  catheter 
should  be  introduced  into  the  bladder.  This  mode  of  procedure, 
it  may  here  be  mentioned,  is  the  one  which  leads  most  speedily 
and  decisively  to  a  true  appreciation  of  the  abnormal  phenomena 
in  those  rare  cases  of  anasarca  which  are  produced  by  distention 
of  the  bladder,  and  of  which  Trousseau  has  recorded  several. 

The  Gravid  Uterus. — A  gravid  womb  is  readily  distinguished 
from  abdominal  dropsy  by  the  peculiar  form  of  the  dulness  on 
percussion,  its  steady  and  uniform  increase  corresponding  to  the 
enlargement  of  the  womb,  the  absence  of  fluctuation,  the  detection 
of  the  sounds  of  the  foetal  heart,  the  alteration  in  the  color  and 
appearance  of  the  mammary  areola,  and  the  production  of  move- 
ments in  the  womb  on  making  an  examination  per  vaginam. 
Very  much  the  same  signs,  too,  enable  us  to  discriminate  between 
a  gravid  uterus  and  ovarian  dropsy. 

Chronic  Tympanites. — A  great  prominence  of  the  abdomen, 
due  to  flatulent  distention  of  the  bowels,  is,  if  at  all  a  persistent 
state,  very  apt  to  be  mistaken  for  dropsy  of  the  belly.  But  the 
large  abdomen  yields  not  a  dull,  but  everywhere  a  tympanitic 
sound,  and  there  is  no  fluctuation.  Then,  as  we  shall  presently 
discuss,  the  history  of  the  case  and  the  attending  symptoms  throw 
light  upon  the  nature  of  the  ailment. 

*  In  a  case  recorded  by  Watson,  in  his  Lectures  on  the  Practice  of  Physic, 
although  the  bladder  was  enormously  distended,  large  quantities  of  urine 
were  constantly  passing  from  the  patient. 


600  MEDICAL    DIAGNOSIS. 

Besides  the  complaints  just  reviewed,  which  are  those  most  com- 
monly confounded  with  ascites,  there  are  a  few  very  rare  disorders 
which  might  be  mistaken  for  collections  of  fluid  in  the  peritoneal 
sac.  They  are:  dropsy  of  the  womb;  dropsy  of  the  Fallopian 
tubes;  dropsy  of  the  omentum;  very  large  serous  cysts  in  the 
kidney ;  hydatids  of  the  liver,  of  size  so  great  as  to  lead  to  general 
abdominal  distention ;  and  a  dilatation  of  the  stomach  so  exten- 
sive that  the  viscus  occupies  almost  the  whole  abdomen.  With 
reference  to  the  latter  affection,  which  has  been  chiefly  encountered 
in  cases  of  boulimia,  and  in  cancer  of  the  pylorus  or  stricture  of 
the  duodenum,  we  may  distinguish  it  from  ascites  by  the  history 
of  the  case  and  the  vomiting  and  other  marked  gastric  symptoms, 
by  the  gurgling  discerned  on  sudden  pressure,  by  the  extended 
tympanitic  percussion  note,  by  the  indistinct  fluctuation,  which  is 
not  noticed  except  over  the  most  dependent  part  of  the  organ,  by 
the  splashing  or  the  metallic  or  amphoric  sounds  which  are  per- 
ceived when  its  contents  are  agitated,*  and  by  the  length  to  which 
the  stomach-tube  can  be  introduced.  The  other  maladies  men- 
tioned can  be  separated  only  by  taking  into  account  their  history 
and  progress,  and  by  laying  stress  upon  the  absence  of  those 
morbid  states  which  generally  cause  ascites,  and  upon  the  occur- 
rence of  special  phenomena  which  point  to  the  structures  impli- 
cated. 

Chronic  Tympanites. — A  collection  of  gas  in  the  cavity  of 
the  peritoneum  is  of  rare  occurrence,  but  is  frequent  in  the  in- 
testinal tube,  and  the  accumulation  becomes  sometimes  a  chronic 
condition,  and  leads  to  very  great  and  uniform  enlargement  of 
the  abdomen.  We  find  this  form  of  tympanites  in  some  cases  of 
hysteria ;  in  instances  of  constriction  of  portions  of  the  intestinal 
canal,  in  consequence  either  of  cicatrization,  or  of  cancer  of  the 
bowels,  or  of  their  compression  by  a  morbid  growth  ;  as  a  sequel 
of  enteritis  or  peritonitis,  or  of  a  spinal  lesion;  and  we  also  observe 
it  in  persons  whose  digestive  powers  are  weak  and  who  partake 
much  of  food — such  as  cabbages,  beans,  and  peas — which  is  apt  to 
occasion  flatulency. 

*  See  cases  of  great  enlargement  of  the  stomach,  by  Oppolzer,  quoted  in 
the  American  Journal  of  the  Medical  Sciences,  Jan.  1869 ;  Schultze,  Berlin. 
Klin.  Wochenschrift,  1874 ;  Penzoldt,  Die  Magenerweiterung,  1875 ;  Ross, 
Montreal  Hospital  Reports,  vol.  i.,  1880. 


ABDOMINAL    ENLARGEMENT.  601 

Among  soldiers  this  chronic  tympanites — owing,  perhaps,  in 
many  cases  to  the  character  of  their  diet  and  consequent  digestive 
disturbances — is  far  from  being  an  uncommon  disorder,  and  may 
be  a  very  obstinate  one.  It  gives  rise  to  abdominal  enlargement, 
which  is  constantly  mistaken  for  dropsy,  but  which  does  not  yield 
a  sense  of  fluctuation,  or  return,  on  percussion,  any  other  than  a 
well-marked  tympanitic  sound.  The  distention  produces,  more- 
over, an  inability  to  take  active  exercise,  sensations  of  cutting  pain 
under  the  ribs,  and  palpitation  of  the  heart;  pressure  on  the  ab- 
domen occasions  much  discomfort;  the  soldiers,  therefore,  walk 
with  their  clothes  unbuttoned,  and  find  it  very  irksome  to  wear 
their  belts.  They  are  sometimes  troubled  by  indigestion,  and  feel 
particularly  uncomfortable  after  meals;  or  the  symptoms  of  indi- 
gestion, although  they  may  have  been  present  at  the  beginning  of 
the  complaint,  disappear,  but  the  swelling  of  the  abdomen  persists 
for  many  months.  According  to  my  experience,  the  ailment  is 
always  gradual  in  its  development. 

Partial  Abdominal  Enlargement. 

Abdominal  Tumors. — I  propose  here  to  offer  a  few  observa- 
tions on  abdominal  tumors,  even  at  the  risk  of  repeating  much 
that  has  been  already  said  while  discussing  affections  of  individual 
abdominal  viscera.  But  for  clinical  purposes  it  is  a  matter  of 
convenience  to  point  out  connectedly  the  relations  an  abdominal 
swelling  is  likely  to  bear  to  the  normal  structures  of  the  abdom- 
inal cavity,  and  to  consider,  moreover,  the  swelling  as  constituting 
the  starting-point  of  our  diagnosis. 

Let  us  first  examine  the  meaning  of  an  abdominal  tumefaction 
occupying  solely  or  principally  one  region  of  the  abdomen. 

Right  Hypochondrium. — The  most  usual  cause  of  a  tumor  in 
this  region  is  an  enlargement  of  the  liver,  whether  that  enlarge- 
ment be  due  to  congestion,  to  fatty  or  waxy  degeneration,  to 
chronic  hepatitis,  to  cancer,  to  hydatids,  or  to  an  abscess.  Some- 
times a  tumor  which  seems  to  be  principally  in  the  right  hypo- 
chondrium, or  to  proceed  from  the  termination  of  this  region,  is 
simply  a  displaced  liver,  or  an  affection  of  the  gall-bladder.  In 
the  first  instance,  the  recognition  of  the  disorder — such  as  a  pleu- 
ritic effusion — which  has  given  rise  to  the  displacement ;  in  the 


602  MEDICAL    DIAGNOSIS. 

second,  the  history  of  the  case,  the  shape  of  the  swelling,  and  the 
symptoms  attending  it, — will  give  us,  as  has  been  elsewhere  indi- 
cated, an  insight  into  its  cause.  Again,  a  tumor  in  the  parts 
mentioned  may  be  due  to  an  enlarged  kidney, — enlarged  either  by 
cancerous  transformation  or  by  cystic  degeneration.  Careful  ex- 
aminations of  the  urine  and  the  history  of  the  case  furnish  the 
most  certain  means  of  discrimination.  Then  we  must  also  bear  in 
mind  that  all  enlarged  kidneys  displace  the  bowel  in  a  particular 
manner;  they  press  it  forward,  and  the  dulness  over  the  tumor  is 
largely  mixed  with  a  tympanitic  sound,  or  the  dulness  is,  indeed, 
not  very  appreciable. 

Left  Hypochondrium. — The  most  usual  tumors  in  this  region 
are  those  produced  by  enlargement  of  the  spleen.  Now,  an  in- 
crease in  size  of  this  viscus,  if  acute,  is  generally  owing  either  to 
inflammation  or  to  altered  blood  conditions,  as  in  pyaemia',  puer- 
peral fever,  and  acute  tuberculosis,  or  to  those  changes  in  its  struc- 
ture which  take  place  during  typhoid,  relapsing  fever,  or  the  ma- 
larial fevers.  Under  the  latter  circumstances,  the  cause  of  the 
swelling  is  disclosed  by  the  history  of  the  case  and  the  symptoms 
accompanying  the  fever. 

Inflammation  of  the  spleen  is  an  affection  very  difficult  to  recog- 
nize. The  most  trustworthy  symptoms  are :  pain  in  the  left 
hypochondrium,  radiating  thence  in  various  directions,  as  far  as 
the  left  shoulder,  and  augmented  by  pressure,  especially  if  the 
serous  envelope  be  implicated,  by  coughing,  and  by  a  deep  inspi- 
ration ;  nausea ;  vomiting ;  fever  having  irregular  fits  of  exacer- 
bation ;  sometimes  delirium,  dry  cough,  and  a  sense  of  suffocation. 
The  extent  of  the  splenic  percussion  dulness  is  decidedly  increased, 
and,  when  we  are  sure  that  the  spleen  is  not  displaced,  the  sud- 
denly-widened area  of  dulness  forms  a  most  important  element  in 
the  diagnosis.  Splenitis  is  generally  metastatic.  It  is  often  ob- 
served to  be  connected  with  emboli  resulting  from  endocarditis, 
and,  these  being  wafted  also  to  the  kidneys,  albumen  and  blood 
are  found  in  the  urine,  caused  by  the  metastatic  inflammation. 
When  suppuration  in  the  spleen  ensues,  the  fever  may  assume  a 
hectic  character  and  the  patient  lose  flesh  rapidly,  while  the  spleen 
increases  in  size.  But  there  is  no  certainty  in  these  signs,  nor, 
indeed,  in  any  of  the  signs  of  splenic  abscess;  this  may  be  latent 
and  suddenly  rupture  into  the  abdominal  cavity  or  the  stomach. 


ABDOMINAL    ENLARGEMENT.  603 

Chronic  enlargement  of  the  spleen  may  be  caused  by  hypertrophy, 
by  waxy  disease,  by  fibrinous  infiltration,  by  malignant  growth, 
by  hydatids,  by  syphilitic  tumor,  and  by  congestion  with  subse- 
quent structural  changes,  such  as  occur,  for  instance,  in  miasmatic 
affections.  There  are  scarcely  any  symptoms  which  are  charac- 
teristic of  these  states,  except  it  be  the  alteration  the  blood  under- 
goes, as  evinced  by  a  diminution  of  the  red  globules  and  an  increase 
of  the  white,  and  the  waxy  hue  of  the  face ;  and  even  these  may 
not  happen.  Dropsy,  bleeding  from  the  nose,  from  the  stomach,  or 
from  the  intestinal  canal,  and  digestive  disturbances,  though  far 
from  infrequent,  are  less  constant,  and  have  not  thus  as  available 
diagnostic  value.  And  in  truth  all  of  the  phenomena  mentioned, 
except  perhaps  the  microscopical  evidences  of  deteriorated  blood, 
are,  in  the  recognition  of  a  splenic  tumor,  of  secondary  importance 
as  compared  with  the  extended  percussion  dulness  in  the  splenic 
region.  There  is  said  to  be  a  constant  relation  between  the  vari- 
ations of  the  volume  of  the  spleen  and  of  the  temperature.*  In 
some  cases  the  symptoms  are  very  ill  defined,  and  death  may  result 
from  rupture  of  varices  of  the  enlarged  viscus,  without  any  other 
signs  of  a  lesion  than  those  of  increased  size  of  the  organ.f  When 
enlargement  of  the  spleen  has  reached  a  certain  point,  the  organ 
curves  into  the  hypogastric  and  right  iliac  regions,  and  a  notch  or 
notches  may  be  felt  on  its  anterior  and  inner  surfaces. J  This  sign 
may  be  very  valuable  in  distinguishing  the  enlarged  organ  from 
cancer  of  the  kidney,  for  which  it  has  been  mistaken. § 

Having  determined  the  persistent  swelling  to  be  due  to  the  ab- 
normal size  of  the  spleen,  we  must  next  endeavor  to  ascertain  the 
cause  of  it.  The  history  of  the  case  forms,  with  the  coexisting 
phenomena  in  other  organs,  in  this  inquiry,  the  main  element  in 
diagnosis. 

A  fulness  projecting  from  the  left  hypochondrium  toward  the 
umbilical  or  lumbar  region  may  be  owing  to  fcecal  accumulations 
in  the  colon,  as  well  as  to  an  enlarged  spleen.  Now,  although 
these  faecal  accumulations  do  not  occur  so  often  in  or  near  either 

*  American  Journal  of  the  Medical  Sciences,  July,  1867. 
f  Traube,  Virchow's  Archiv,  and  British  and  Foreign  Medico-Chirurgical 
Beview,  Oct.  1869. 
%  Fagge,  Guy's  Hospital  Eeports,  1868. 
I  Lancet,  July,  1873. 


604  MEDICAL    DIAGNOSIS. 

hypochondrium  as  they  do  in  the  iliac  regions,  yet  they  are  not 
very  uncommon,  and  we  should  be  on  our  guard  against  con- 
founding them  with  organic  disease,  whether  of  the  stomach, 
spleen,  liver,  kidneys,  peritoneum,  or  ovary.  Their  irregular 
outline,  a  doughy  consistence  and  painlessness,  and  close  attention 
to  the  history  of  the  case  and  to  the  accompanying  disorder  of  the 
digestive  functions,  will  generally  enable  us  to  detect  the  true 
nature  of  the  swelling.  But  we  must  not  lay  stress  on  the  non- 
existence of  constipation,  for  sometimes  great  irritability  of  the 
bowels  or  persistent  diarrhoea  is  kept  up  by  a  large  collection  of 
faecal  matter  in  the  colon.  Repeated  attacks  of  colicky  pains  and 
some  soreness  to  the  touch  are  not  unusual  in  cases  of  extensive 
faecal  accumulation,  and  jaundice  and  anaemia  have  also  been 
noticed.  In  cases  of  doubt,  laxatives,  especially  castor  oil,  should 
be  employed  before  any  opinion  is  given,  and  with  the  voiding  of 
large  hard  fsecal  masses  the  tumor  and  the  attending  symptoms 
may  disappear. 

As  regards  swellings  of  any  kind  situated  in  either  hypochon- 
drium, or  in  fact  at  any  portion  of  the  upper  third  of  the  abdo- 
men, it  is  always  to  be  inquired  into  whether  they  are  affected  by 
the  act  of  respiration.  This,  as  Kennedy*  has  pointed  out,  is  a 
very  valuable  sign,  for  if  the  morbid  mass  move  in  consequence 
of  the  depression  of  the  diaphragm,  it  is  because  structures  are 
involved,  such  as  the  stomach  and  transverse  colon,  the  liver  or 
spleen,  which  admit  of  some  mobility  ;  whereas  a  tumor  that  is 
uninfluenced  must  appertain  to  a  fixed  part, — for  instance,  to  the 
aorta. 

Epigastrium. — The  most  common  cause  of  an  epigastric  tumor 
is  cancer  of  the  stomach.  The  swelling  is  then  associated  with 
extreme  gastric  acidity,  with  frequent  vomiting,  with  pain,  and 
with  gradual  and  progressive  loss  of  flesh,  and  debility. 

But  a  tumor  in  this  region  may  be  also  produced  by  a  disease 
of  the  pancreas.  Now,  practically  speaking,  there  is  but  one  affec- 
tion of  the  pancreas  which  we  can  recognize  with  anything  like 
certainty, — cancer;  for  neither  acute  nor  chronic  pancreatitis,  nor 
atrophy,  whether  happening  in  diabetes  or  independently,  nor 
fatty  degeneration,  nor  uniform  simple  hardening  of  the  gland, 

*  Dublin  Quarterly  Journal,  August,  1864. 


ABDOMINAL    ENLARGEMENT.  605 

can,  as  a  rule,  be  discerned  at  the  bedside.  With  reference  to  the 
two  forms  of  inflammation,  we  suspect  their  presence  if  there  be 
deep-seated  epigastric  pain  with  colicky  attacks,  if  a  large  quan- 
tity of  matter  like  saliva  be  passed  by  stool,  or  if  profuse  sali- 
vation happen.  But  though  these  symptoms  have  been  observed 
iu  individual  cases,  they  are  far  from  being  constant.  An  acute 
parenchymatous  inflammation  is  not  uncommon  in  acute  infec- 
tious diseases.  In  chronic  pancreatitis  sugar  in  the  urine,  fatty 
stools,  and  jaundice  have  been  several  times  observed  to  attend 
the  appreciable  swelling  extending  across  the  epigastrium.  As 
regards  cancer,  the  most  trustworthy  symptoms  are:  a  tumor  in 
the  epigastric  region ;  pain  there  or  in  the  back,  not  increased  by 
the  taking  of  food,  but  usually  augmeuted  by  the  erect  posture; 
progressive  emaciation  and  debility;  an  appetite  capricious  rather 
than  diminished,  and  in  some  instances,  indeed,  a  ravenous  desire 
for  food ;  constipation,  and  at  times,  but  far  from  invariably,  fatty 
stools.*  Besides  these  indications,  we  not  uncommonly  find,  as 
the  disease  advances,  obstinate  jaundice  and  occasional  vomiting. 
Many  of  these  phenomena  belong  also  to  cancer  of  the  stomach  ; 
in  truth,  we  never  can  be  certain  of  the  existence  of  the  pancreatic 
malady  until  we  have  excluded  the  gastric  affection.  In  a  differen- 
tial diagnosis  of  this  kind,  the  early  presence  and  habitual  occur- 
rence of  vomiting  after  meals,  the  sour  eructations,  the  hsemate- 
mesis,  and  the  absence  of  jaundice,  assist  us  in  locating  the  seat  of 
the  disease  in  the  stomach. 

An  epigastric  tumor  is  sometimes  simulated  by  a  contraction  of 
the  upper  portion  of  the  rectus  muscle  on  palpation ;  but  the 
swelling  in  the  latter  case  generally  soon  subsides,  especially  if 
rubbed.  Occasionally,  however,  a  tumefaction  due  to  contraction 
of  an  abdominal  muscle  may  be  of  some  duration.f  And  I  have 
known  a  contraction  of  the  rectus  muscle  in  a  case  of  gastric  cancer 
occasion  so  obvious  a  resistance  and  swelling  that  it  was  looked 
upon  as  due  to  malignant  disease  of  the  intestine,  or  of  the  peri- 
toneum. Moreover,  the  rigid  muscle  gave  rise  to  dulness  on 
percussion.     But  though  the  phenomena  lasted  for  some  -time, 

*  In  analyzing  forty  cases  that  have  been  placed  on  record  by  different 
authors,  and  some  that  have  come  under  my  own  notice,  I  do  not  find  this 
symptom  mentioned  in  one-third. 

f  Greenhow's  cases,  Lancet,  1857. 


606  MEDICAL    DIAGNOSIS. 

and  were  indeed  for  a  lengthened  period  a  marked  feature  of 
the  case,  it  was  observable  that  the  muscle  was  raised  and  rigid 
to  a  decided  degree  only  in  certain  positions ;  at  all  events,  that 
certain  positions  gave  a  distinct  outline  to  the  swelling,  and  that 
the  latter  then,  like  the  line  of  dulness,  was  regular  and  straight, 
evidently  corresponding  to  the  contour  of  the  muscle.  And  this 
occurs  in  all  instances  of  contraction  of  the  rectus,  no  matter  with 
what  associated. 

The  muscular  contractions  are  not  always  confined  to  one 
muscle,  or  to  the  whole  of  one  muscle,  and  when  irregular,  and 
particularly  when  associated  with  tympanitic  distention  of  the 
intestine,  give  rise  to  most  of  the  so-called  "phantom"  tumors 
of  the  abdomen.  These  swellings  are  perplexing,  and  are  con- 
stantly mistaken  for  serious  abdominal  tumors.  The  history  of 
the  case,  the  absence  generally  of  grave  constitutional  symptoms, 
the  most  frequent  occurrence  of  the  tumefaction  in  females,  es- 
pecially in  hysterical  females,  and  the  usually  coexisting  con- 
stipation, furnish  us  with  valuable  signs  of  distinction.  But  I 
believe  the  use  of  anaesthetics  to  be  the  most  important  means  of 
diagnosis.  I  was  first  led  to  employ  them  a  number  of  years 
ago,  in  a  case  which  had  baffled  the  skill  of  several  eminent  sur- 
geons,  one  of  whom  had  proposed  to  the  patient  an  operation  as 
the  only  means  of  relief  from  what  was  considered  an  ovarian 
disease.  The  patient  was  thirty-one  years  of  age,  a  widow,  and 
evidently  of  highly  hysterical  temperament.  She  was  very  subject 
to  constipation  ;  and  the  swelling  of  which  she  complained  was  of 
irregular  outline  and  occupied  the  centre  of  the  abdomen,  extend- 
ing; some  distance  on  each  side  of  the  median  line.  It  was  hard 
and  resisting  to  the  touch,  but,  on  strong  percussion,  yielded  a 
tympanitic  sound.  Whenever  it  was  touched  she  shrank.  Thor- 
ough relaxation  was  produced  by  the  administration  of  ether;  the 
hand  could  be  pressed  almost  against  the  vertebral  column,  and 
all  signs  of  the  tumor  disappeared.  A  complete  recovery  took 
place;  and  thus  terminated  a  case  which  had  lasted  for  fully  one 
year,  .and  in  which  it  is  highly  probable,  from  the  fact  that  the 
patient  was  fond  of  having  her  urine  drawn  off  by  the  catheter, 
and  had  shown  other  manifestations  of  a  similar  type  of  hysteria, 
that  the  swelling  was  in  part  at  least  artificially  produced.  But  in 
any  of  the  phantom  tumors  I  would  recommend  the  use  of  anses- 


ABDOMINAL  ENLARGEMENT.  607 

thetics  for  purposes  of  diagnosis;  nay,  they  may  be  most  advan- 
tageously employed,  for  similar  reasons,  in  all  cases  of  abdominal 
swelling  in  which  the  rigid  state  of  the  abdominal  walls  interferes 
with  accuracy  of  investigation. 

In  soldiers  we  at  times  observe  one  or  several  small  movable 
tumors,  yielding  a  tympanitic  sound  on  percussion,  in  the  epigas- 
tric or  at  the  upper  part  of  the  umbilical  region.  Their  nature 
is  very  obscure :  they  are,  probably,  small  portions  of  intestine 
which  have  been  pushed  between  the  fasciculi  of  a  ruptured  rectus 
muscle. 

Umbilical  Region. — Tumors  which  are  found  in  this  region 
form,  as  a  rule,  merely  portions  of  a  swelling  that  is  principally 
seated  in  the  epigastrium  or  the  hypochondria,  such  as  cancer  of 
the  stomach,  of  the  liver,  of  the  pancreas,  or  of  the  omentum, 
and  dilatation  of  the  gall-bladder.  The  only  two  affections  which 
are  apt  to  occasion  a  swelling  solely,  or  at  least  principally,  limited 
to  and  perceptible  in  the  umbilical  region,  are  tuberculous  disease 
of  the  mesenteric  glands  and  a  movable  kidney. 

The  symptoms  of  the  former  malady,  or  tabes  mesenterica,  are 
much  the  same  as  those  of  tubercular  peritonitis.  Indeed,  unless 
the  enlarged  mesenteric  glands  can  be  felt  through  the  abdom- 
inal parietes,  the  discrimination  is  uncertain.  The  abdomen  is 
prematurely  large,  is  slightly  tender  on  pressure,  and  has  often  a 
doughy  feel ;  the  child — for  it  is  almost  exclusively  in  children 
that  the  disease  is  seen — loses  flesh,  the  digestion  is  impaired,  the 
evacuations  are  frequent  and  unhealthy.  It  often  presents  signs 
of  scrofulous  disease  elsewhere;  and  under  such  circumstances  we 
cannot  be  at  a  loss  in  determining  the  nature  of  the  tumefaction 
in  the  umbilical  region.  The  simulation  of  the  disease  in  adults, 
especially  in  young  women,  by  mere  ataxia  and  probable  func- 
tional disorder  of  the  glands,  has  been  described  in  reviewing  the 
affections  of  the  stomach. 

When  the  kidneys  are  not  firmly  held  by  their  attachments,  they 
become  displaced,  and  are  then  apt  to  give  rise  to  serious  errors 
in  diagnosis.  The  dislocated  organ  is  generally  perceived  under 
the  margin  of  the  ribs  on  the  right  flank,  or  in  the  umbilical 
region,  and  sometimes  extends  across  the  median  line.  The  ap- 
parently morbid  mass  is  easily  moved,  may  be,  by  careful  and 
methodical  pressure,  returned  to  the  renal  region,  and  presents,  on 


608  MEDICAL    DIAGNOSIS. 

percussion,  the  outline  of  the  kidney.  The  lumbar  region  yields 
a  tympanitic  sound  on  percussion,  and  we  find  less  resistance  and 
a  slight  depression  over  the  usual  seat  of  the  organ,  which  depres- 
sion is  effaced  by  pressing  the  tumor  into  the  lumbar  region. 
There  is  in  some  instances  sensitiveness  over  the  displaced  organ, 
especially  after  fatigue,  or  a  blow,  or  strong  pressure ;  and  press- 
ure in  examining  the  part  is  very  apt  to  give  rise  to  the  same 
sensation  as  when  the  renal  region  of  the  non-affected  side  is 
pressed;  but  we  never  find  any  disturbance  of  the  urinary  func- 
tions, nor,  in  fact,  except  a  disagreeable  feeling  in  walking, 
does  any  real  inconvenience  result  from  the  accident,  save  in 
those  cases  in  which  the  movable  kidney  has  become  painful,  or, 
by  compressing  the  vena  cava  or  portal  veins,  occasions  dropsy. 
The  disorder  is  most  apt  to  occur  after  violent  exertion,  or  after 
many  pregnancies,  or  may  be  due  to  attacks  of  congestion  of  the 
organ.  The  right  kidney  is  more  frequently  movable  than  the 
left.  Women  are  more  liable  to  displacements  of  the  organ  than 
men;*  and  there  seems  to  be  a  special  connection  between  the  dis- 
order and  hysteria,  f 

The  affection  may,  of  course,  be  mistaken  for  any  form  of 
abdominal  tumor,  and  if  the  kidney  should  have  become  ad- 
herent the  diagnosis  is  very  uncertain.  Generally  the  disorder 
can  be  distinguished  by  the  absence  of  signs  of  constitutional 
disturbance ;  by  the  history  of  the  case ;  and  by  the  physical 
phenomena  already  alluded  to.  To  these  may  be  added  the 
comparatively  slight  dulness  or  rather  the  tympanitic  character 
of  sound  elicited,  except  on  very  strong  percussion,  over  the  seat 
of  the  tumor.  This  is  an  important  fact  as  regards  the  dis- 
crimination of  a  movable  and  displaced  spleen,  in  which,  as  the 
organ  is  generally  enlarged,  there  is  considerable  and  extended 
dulness  on  percussion.  Moreover,  the  history  of  the  splenic  dis- 
order, which  not  uncommonly  can  be  traced  to  a  malarial  affec- 
tion, the  usually  great  tenderness,  the  nausea,  dyspeptic  symptoms, 

*  See  the  cases  of  Henoch,  Klinik  der  Unterleibs-Krankheiten  ;  and  of 
Fritz,  Arch.  Gen.  de  Medecine,  1859;  Becquet,  ib.,  Jan.  1865;  Hare,  Med. 
Times  and  Gazette,  1860  ;  Oppolzer,  quoted  in  Canst.  Jabrb.,  vol.  iii.  p.  212; 
Durham,  Guy's  Hospital  Eeports,  vol.  ix.,  3d  Series  ;  Trousseau,  Clinique 
Medicale  ;  and  Schmidt's  Jahrb.,  No.  2,  1880. 

f  Schmidt's  Jahrb.,  No.  2,  1871. 


ABDOMINAL    ENLARGEMENT.  609 

and  hemorrhagic  tendencies  which  attend  the  displacement  of  the 
spleen,  will  assist  us  in  our  diagnosis.* 

Yet  another  of  the  abdominal  organs  is  occasionally  displaced 
and  movable, — the  liver.  Now,  a  movable  liver  would  be  often 
mistaken  for  a  movable  spleen,  were  it  a  more  common  affec- 
tion. But  very  few  well-authenticated  cases  are  on  record. f  In 
these  the  peritoneal  attachment  of  the  organ  had  become  lax, 
usually  in  consequence  of  pregnancy  ;  in  the  hepatic  region  there 
was  a  tympanitic  sound  on  percussion;  and  in  the  umbilical  re- 
gion and  toward  the  right  flank  a  solid  body  was  discerned,  the 
upper  border  of  which  presented  a  convex  outline,  the  lower 
border  was  in  the  inguinal  region.  The  displaced  organ  was 
easily  pushed  about,  and  could  be  replaced  in  its  proper  situation. 
The  spleen  was  found  in  its  usual  seat ;  the  symptoms  were 
merely  those  of  weight  and  uneasiness  in  the  abdomen.  The 
movable  or  wandering  organ  may  be  painful  or  painless.  It  has 
the  physical  characters  of  the  liver,  and  the  most  certain  sign  is 
the  detection,  on  palpation,  of  the  notch  between  the  right  and 
the  left  lobe.  The  diagnosis  is,  however,  always  difficult  and 
doubtful.  New  growths  of  the  kidney,  as  a  case  of  Legg's  proves, 
are  particularly  apt  to  be  confusing.  In  most  recorded  cases  au- 
topsies are  wanting ;  and  the  whole  subject  is  very  obscure.  The 
affection  is  more  usual  in  women  than  in  men,  and,  besides  preg- 
nancy, tight  lacing  and  chronic  inflammation  of  the  peritoneum 
are  said  to  lead  to  it. 

Lumbar  Region. — Tumors  in  this  region,  or  on  either  flank, 
are  apt  to  be  occasioned  by  some  morbid  growth  of  the  kidney,  or 
by  an  abscess  in  it  or  its  surroundings,  or  in  the  psoas  muscles. 
Again,  they  may  be  due  to  faecal  accumulations;  or,  if  on  the 
right  side,  to  very  considerable  increase  of  the  liver;  if  on  the 
left,  to  a  greatly  enlarged  spleen.  To  discriminate  between  these 
different  conditions,  we  have  to  determine  whether  the  swelling 

*  Cases  of  displaced  spleen  are  recorded  by  Dietl,  "Wiener  Med.  Wochen- 
schrift,  No.  23,  1856,  also  in  Archives  Generales,  1858,  tome  ii. ;  Brit,  and 
For.  Med.-Chir.  Eev.,  Oct.  1880:  see,  too,  Clarke,  Dubl.  Hosp.  Gazette,  Aug. 
1860 ;  and  Med.  Times  and  Gazette,  Nov.  1869. 

f  See  Cantani,  Ann.  Univers.  di  Medicina,  1866  ;  and  Meissner's  article  in 
Schmidt's  Jahrb.,  1869,  No.  1 ;  also,  ib.,  No.  2,  1871 ;  Blet,  Le  Foie  Mobile, 
These  de  Paris,  1876;  Legg,  St.  Bartholomew's  Hospital  Beports,  1877. 

39 


610  MEDICAL    DIAGNOSIS. 

fluctuates  or  not;  we  must  also  analyze  the  urine,  and  inquire 
minutely  into  the  circumstances  preceding  and  attending  the  tume- 
faction. It  is  thus  only  that  we  can  hope  to  attain  the  necessary 
data  for  a  diagnosis,  which  has,  indeed,  often  to  be  reached  by  the 
process  of  exclusion. 

Tumors  behind  the  peritoneum  may  give  rise  to  a  visible  promi- 
nence in  either  lumbar  region,  extending  to  the  upper  part  of  the 
iliac  region.  The  most  common  cause  of  these  tumors  is  cancer 
of  the  lymphatic  (/lands  lying  by  the  sides  or  in  front  of  the  ver- 
tebral column.  The  disease  is  very  difficult  of  detection.  Still, 
we  may  suspect  its  existence  if,  in  a  patient  who  is  evidently 
cachectic,  and  who  is  steadily  losing  flesh  and  strength,  we  dis- 
cover, on  deep  palpation  on  one  side  of  the  linea  alba  or  in  the 
flank,  a  tumor  which,  owing  to  its  being  surrounded  by  intestine, 
returns  a  tympanitic  percussion  sound.  In  some  cases  the  swelling 
communicates  the  beat  of  the  aorta  and  simulates  an  aneurism, 
or  it  presses  on  the  vena  cava  and  gives  rise  to  enlargement  of 
the  abdominal  veins  and  of  those  of  the  lower  extremities,  and 
to  oedema  of  the  legs.  The  disease  may  involve  the  iliac  glands 
and  the  tumor  extend  into  the  pelvis,  or  it  may  reach  upward  to 
the  diaphragm ;  and  by  the  cancer  spreading  to  the  posterior 
mediastinum  and  softening,  it  may  finally  open  into  the  aorta, 
producing  hemorrhages  precisely  like  those  coming  from  an  aneu- 
rismal  sac* 

Iliac  Regions. — Tumors  in  either  of  these  regions  may  be  due 
to  many  different  causes.  They  are,  as  we  have  elsewhere  dis- 
cussed, principally  owing  to  ovarian  affections ;  to  fsecal  accumu- 
lations; to  disease  of  the  large  intestine,  such  as  intussusception 
or  cancer ;  and  to  pelvic  abscess.  Sometimes  they  are  caused  by 
displacement  of  the  kidney,  by  enlargement  of  the  spleen,  and  in 
women  by  periuterine  hematocele,  or  by  extra-uterine  pregnancy. 

The  ovarian  tumors  are,  as  a  rule,  distinguished  from  the  other 
disorders  mentioned  by  their  more  or  less  globular  form,  by  their 
movability  from  side  to  side  or  in  an  upward  direction,  by  their 
seeming  to  spring  out  of  the  pelvis,  and  their  evident  attachment 
below,  by  the  displacement  of  the  womb,  by  the  comparatively 
unimpaired  general  health,  and  by  their  indolent  and  generally 


*  Case  reported  by  Haldane,  Edinburgh  Medical  Journal,  Aug.  1868. 


ABDOMINAL    ENLARGEMENT.  611 

painless  nature.  These  remarks  do  not  apply  to  the  very  slight 
swelling  occasioned  by  ovarian  inflammation,  for  here  the  tumid 
spot  is  often  the  seat  of  severe  pain.  The  healthy  ovary  is  not 
sensitive  to  the  touch.  To  examine  the  ovary  with  exactness,  the 
abdominal  muscles  must  be  as  completely  as  possible  relaxed ;  the 
patient  is  best  placed  in  the  attitude  recommended  by  Marion 
Sims, — on  her  back,  with  the  shoulders  supported,  the  legs  drawn 
up  so  that  the  heels  are  a  few  inches  asunder,  and  that  the  thighs 
fall  easily  apart. 

But  to  return  to  ovarian  tumors.  As  these  grow  and  spread 
upward  they  give  rise  to  difficulties  in  diagnosis,  which  we  have 
already  examined  into,  as  far  at  least  as  is  possible  in  a  work  of 
this  kind.  We  may  here  again  allude  to  the  manner  in  which 
ovarian  may  simulate  renal  growths, — a  similarity  so  close  that 
even  so  accomplished  an  expert  as  Spencer  Wells  has  been  de- 
ceived. This  authority  dwells  particularly*  on  the  absence  of 
fluctuation  in  the  vast  majority  of  instances  of  enlarged  kidney ; 
on  the  renal  tumor  being  first  detected  between  the  false  ribs  and 
the  ilium ;  on  the  signs  in  the  urine,  and  on  the  absence  of  those 
changes  in  the  quantity  and  regularity  of  the  menstrual  discharges 
which  are  common  in  ovarian  disorders.  Moreover,  the  ovarian 
growth  usually  displaces  the  intestine  backward ;  in  the  renal 
growth  it  is  pressed  forward ;  and  large  tumors  of  the  right 
kidney  ordinarily  have  the  ascending  colon  on  their  inner  border, 
while  tumors  of  the  left  kidney  are  generally  crossed  from  above 
downward  by  the  descending  colon. 

Among  the  causes  of  a  tumor  in  either  iliac  fossa  periuterine 
hcematocele  has  been  mentioned.  The  tumor  rising;  above  the 
brim  of  the  pelvis  is  traceable  into  it,  and  the  quick  manner  in 
which  the  swelling  has  formed,  the  faintness  and  prostration 
which  the  effusion  of  blood  occasioned,  and  the  swelling,  com- 
monly of  rounded  shape,  either  hard  or  soft,  discernible  by  an 
examination  through  the  vagina,  render  the  meaning  of  the  tumor 
generally  a  clear  one.  Much  the  same  physical  phenomena  are 
presented  by  the  swelling  due  to  pelvic  cellulitis.  But  the  slow 
way  in  which  the  tumor  forms,  the  presence  of  that  hot,  puffy, 
thickened,  brawn-like  condition  of  the  vaginal  wall,  so  especially 

*  Dublin  Quarterly  Journal,  Feb.  1867. 


612  MEDICAL    DIAGNOSIS. 

dwelt  upon  by  Simpson,  the  usually  greater  tenderness  of  the 
swelling  felt  through  the  walls  of  the  vagina,  and  the  feverish- 
ness  and  constitutional  symptoms  attending  the  gradual  formation 
of  the  abscess,  are  distinguishing  marks,  except  where  the  contents 
of  the  hematocele  suppurate,  when  for  a  diiferential  diagnosis  we 
may  have  to  rely  on  the  history  of  the  case. 

Hypogastric  Region. — Distention  of  the  bladder  and  enlarge- 
ment of  the  uterus,  whether  produced  by  air,  by  liquid,  by  a 
morbid  growth,  or  by  pregnancy,  are  the  most  usual  sources  of  a 
swelling  in  this  region.  If  due  to  any  one  of  these  causes,  the 
outline  of  the  tumor  is  regular  and  rounded  ;  and  by  the  aid  of 
the  catheter,  of  explorations  through  the  vagina  and  the  rectum, 
and  of  the  history  of  the  case  and  the  attending  symptoms,  we 
are  generally  enabled  to  arrive  at  a  correct  diagnosis. 

A  tumor  in  the  hypogastrium  may  also  have  its  origin  in  splenic 
enlargement,  in  diseases  of  the  peritoneum,  or  in  hematocele.  In 
the  latter  case  it  is  apt  to  be  uniform  and  to  extend  to  the  iliac  fossae. 

In  concluding  this  sketch  of  abdominal  tumors,  we  shall  briefly 
glance  at  those  which  are  likely  to  occupy  more  than  one  region, 
and  sometimes  even  the  whole  or  the  greater  part,  of  the  abdomen. 
In  rare  instances,  a  cancer  of  the  liver,  or  hydatids  of  that  organ, 
or  a  fibrous  tumor  of  the  uterus,  or  a  solid  ovarian  growth,  or 
an  enlarged  spleen,*  or  a  kidney  the  pelvis  of  which  has  become 
enormously  distended  in  consequence  of  obstruction  of  the  ureter, 
may  lead  to  the  formation  of  a  swelling  which  occupies  nearly 
the  entire  abdomen.  But  the  most  usual  cause  of  so  diffuse  a 
tumor  is  malignant  disease  of  the  peritoneum. 

This  affection,  when  very  extensive,  may  give  rise  to  a  uniform 
swelling  stretching  across  the  abdomen,  and  equally  marked  on  both 
sides  of  the  median  line,  or,  as  is  not  at  all  unusual,  to  several 
small  tumors,  which  are  evidently  unconnected  with  any  organ 
beneath.  It  is,  moreover,  apt  to  occasion  a  peritoneal  friction 
sound,  to  exhibit  a  varying  resistance  to  pressure  at  different  points, 
to  lead  to  ascites,  to  loss  of  flesh  and  appetite,  and  chiefly,  by  the 
peritonitis  it  sets  up,  to  the  occurrence  of  fever.  Much  the  same 
symptoms  may  be  produced  by  hydatid  disease  of  the  peritoneum, 

*  As  in  the  case  reported  by  Porter,  Philadelphia  Medical  Times,  June, 
1875,  in  which  the  spleen  weighed  twenty-one  pounds. 


ABDOMINAL    ENLARGEMENT.  613 

though  here  there  is  usually  less  fever,  the  swelling  is  even  more 
irregular,  the  abdominal  enlargement  greater,  and — the  test  which 
alone  is  certain — we  may  be  able  to  detect  the  hydatid  fremitus.* 
Yet  as  regards  this  test  we  must  bear  in  mind  that  a  similar  sen- 
sation is  produced  by  colloid  canecr  of  the  peritoneum,  a  sensation 
of  peculiar  and  very  superficial  fluctuation, f  associated,  however, 
here  with  grave  symptoms  of  cachexia,  and  generally  with  a  rap- 
idly spreading  growth.  Peritoneal  abscesses  enclosed  by  adhesions 
will  also,  if  large,  give  rise  to  several  of  the  signs  of  a  cancer ;  but 
the  history  of  an  antecedent  local  or  general  peritonitis,  the  swell- 
ing not  being  influenced  by  changes  in  the  posture  of  the  patient 
or  by  the  acts  of  respiration,  the  indistinct  fluctuation  of  the  tume- 
faction, and  its  acute  course,  will  ordinarily  enable  us  to  distin- 
guish the  non-malignant  from  the  malignant  affection.  In  rare  in- 
stances the  tumor  may  be  enormous,  increase  rapidly,  yet  be  simply 
fatty.  ThereJ  are  no  means  of  positively  d istinguishing  the  affection. 

In  some  cases,  too,  the  malignant  disease  is  closely  simulated  by 
dilatation  of  the  colon,  caused  ordinarily  by  faecal  tumors.  This, 
though  it  may  present  but  a  single  swelling,  generally  occasions 
several,  which  are  commonly  seated  at  the  middle  third  of  the  ab- 
domen, are  apt  to  appear  on  both  sides,  to  be  movable  and  painless 
and  to  bear  handling  without  pain,  to  change  their  position  slightly 
at  intervals,  and  to  become  occasionally  less  in  size.  Then,  after 
the  case  has  been  for  some  time  under  observation,  we  may  be 
able  to  notice  large  and  characteristic  discharges;  though  we 
must  not  forget  that  a  mere  sluggish  state  of  the  bowels,  or  even 
diarrhoea,  may  exist  while  the  colon  is  dilated  and  perhaps  filled 
with  faecal  accumulations^  Sometimes  the  mass  may  be  seated 
above  the  symphysis  and  be  mistaken  for  a  pelvic  tumor.  Like  a 
cancerous  growth,  it  may  in  time  occasion  occlusion  of  the  intes- 
tine and  the  signs  of  complete  intestinal  obstruction. 

Cancer  of  the  intestine  has  symptoms  similar  both  to  fsecal  accu- 
mulation and  to  cancer  of  the  peritoneum.     The  marked  cachexia 

*  See  the  cases  of  Bright,  in  Clinical  Memoirs  on  Ahdominal  Tumors,  re- 
published from  Guy's  Hospital  Keports  by  the  New  Sydenham  Society. 

f  As  in  the  instances  recorded  by  Albert  Kobin,  Bull,  de  la  Soc.  Anat., 
1873,  and  Vidal,  Bull,  et  Mem.  Soc.  Med.  des  Hopit.,  1874. 

%  See  St.  George's  Hospital  Reports,  vol.  v.,  1870,  p.  253. 

|  For  several  interesting  cases  of  the  disorder,  see  Kennedy,  loc.  cit. 


614  MEDICAL    DIAGNOSIS. 

and  the  signs  of  persistent  and  increasing  narrowing  of  the  bowel, 
as  shown  by  the  flattened  faeces,  the  blood  and  pus  in  the  stools,  the 
frequent  attacks  of  colicky  pains,  and  the  vomiting,  distinguish  it 
from  the  former  affection,  with  which,  moreover,  it  may  be  tem- 
porarily combined.  The  limitation  of  the  swelling,  the  absence 
of  dropsy,  the  character  of  the  stools,  the  frequent  change  in  the 
position  of  the  tumor  and  in  its  distinctness,*  and,  if  it  affect  the 
duodenum,  the  decided  jaundice,  separate  it  from  peritoneal  cancer. 


SECTION   V. 

ABDOMINAL    PULSATION. 

Aortic  Pulsation. — By  far  the  most  frequent  cause  of  a 
pulsation  visible  in  the  abdomen,  and  especially  at  the  epigastric 
region,  is  a  throbbing  of  the  abdominal  aorta.  It  is  common  in 
hysterical  persons.  Some  women  are  liable  to  it  immediately  be- 
fore their  menstrual  periods  or  during  the  earlier  months  of  preg- 
nancy. In  men  it  is  most  often  seen  in  those  who  suffer  from 
inveterate  dyspepsia,  and  is  apt  to  come  on  in  severe  paroxysms, 
which  are  alarming  to  the  patient,  but  which  generally  disappear 
under  brisk  purging.  In  hypochondriacs  whose  abdominal  walls 
are  thin,  the  beating  at  the  epigastrium  may  become  a  source  of 
continued  study  and  distress. 

The  increased  action  of  the  aorta,  or,  as  happens  in  emaciated 
persons,  the  greater  distinctness  with  which  the  beat  of  the  artery 
is  perceived,  without  there  being  really  much,  if  any,  abnormal 
throbbing,  may  be  distinguished  from  an  enlarged  and  somewhat 
displaced  heart  by  the  circumstances  of  the  case  and  the  absence 
of  any  physical  signs  of  cardiac  disease;  and  from  an  aneurism, 
by  the  mode  of  invasion,  and  by  the  want  of  those  signs  which, 
as  will  be  presently  described,  characterize  an  aneurism. 

Abdominal  Aneurism. — Aneurism  of  the  abdominal  aorta 
is  a  disease  of  middle  life,  and  of  males.     Its  most  frequent  cause 

*  Leube,  Ziemssen's  Cyclopaedia. 


ABDOMINAL    PULSATION.  615 

is  excessive  muscular  exercise;  sometimes  it  is  produced  by  a  blow 
on  the  abdomen,  or  by  syphilis.  Its  duration  is  very  uncertain  : 
occasionally  six  or  seven  years  elapse  from  its  earliest  indications 
until  the  fatal  termination ;  not  unusually  the  patient  lives  twenty 
to  thirty  months  after  the  outbreak  of  the  complaint. 

The  chief  symptoms  are  pain,  and  an  absence  of  dropsy,  of 
fever,  or  of  any  considerable  constitutional  disturbance.  The  pain 
is  generally  felt  in  the  back,  or  in  the  right  hypoehondrium,  or 
shooting  down  the  sciatic  nerves  to  the  lower  limbs.  It  may  be 
constant  and  dull,  or  occur  in  protracted  and  violent  paroxysms ; 
ordinarily  there  is  a  persistent  pain  which  has  periods  of  fierce  ex- 
acerbation. The  disproportion  between  its  violence  and  the  other- 
wise almost  unimpaired  health  is  a  striking  and  common  feature 
of  the  disease,  and  is  apt  to  continue  until  the  aneurism  becomes 
very  large  and  occasions  displacement  of  important  organs. 

The  physical  signs  of  an  abdominal  aneurism  are  :  an  impulse 
communicated  to  the  hand  when  placed  over  the  swelling ;  a  sys- 
tolic blowing  sound;  a  thrill;  and  in  some  instances  a  distinct 
prominence  and  alteration  in  the  form  of  the  abdomen.  The 
impulse  corresponds,  with  very  rare  exceptions,  to  the  beat  of  the 
heart,  is  single,  and  ordinarily  very  forcible.  Generally  it  cannot 
be  felt  from  behind ;  it  is  a  beat  discerned  only  anteriorly  and  on 
either  side  of  the  pulsating  sac.  Corresponding  to  the  throbbing 
of  the  tumor,  we  often  hear  a  short  blowing  sound,  sometimes 
perceived  in  the  recumbent  posture  only,  or  a  dull,  muffled  sound; 
but  rarely  are  there  two  sounds.  A  thrill  felt  at  the  same  time 
as  the  pulsation  is  not  unfrequently  noticed ;  still,  it  may  be  absent, 
even  in  large-sized  aneurisms. 

Aneurism  of  the  abdominal  aorta  may  be  confounded  with — 

Rheumatism  ;  Neuralgia  ;  Colic  ; 

Disease  of  the  Spine; 

Aortic  Pulsation; 

Lumbar  and  Psoas  Abscess; 

tmdn-aneurismal  pulsating  tumor. 

The  first  four  of  these  affections  are  likely  to  be  mistaken  for 
an  abdominal  aneurism,  on  account  merely  of  the  pain;  the 
others,  because  of  the  presence  of  pulsation,  or  of  a  swelling,  or 
of  both  pulsation  and  swelling. 

Rheumatism;  Neuralgia;   Colic. — The  pain  caused  by  an  aneu- 


616  MEDICAL    DIAGNOSIS. 

rism  may  closely  simulate  rheumatism  of  the  lumbar  muscles, 
or  sciatica,  or  abdominal  neuralgia,  or  colic.  There  is  nothing  in 
the  pain  itself  which  will  lead  to  the  detection  of  its  origin ;  this 
can  be  effected  only  by  a  recognition  of  the  physical  signs  of  the 
aneurism.  When  these  are  not  well  defined,  the  diagnosis  is 
doubtful.  Yet,  even  when  they  are  slightly  marked  or  absent,  if 
the  pain  be  very  obstinate,  and  we  have  excluded  the  affections 
named  or  cannot  trace  them  to  their  usual  causes,  we  shall  often 
be  right  in  attributing  the  pain  to  an  aneurism.  This  is  especially 
true  as  regards  abdominal  neuralgia  occurring  in  males, — a  dis- 
order which  ought  always 'to  make  us  examine  for  an  aneurism, 
and  which  is  not  unfrequently  found  to  be  due  to  it. 

Disease  of  the  Spine. — Patients  who  are  suffering  from  aneurism 
often  complain  of  pain  in  the  spine,  and  present  sometimes  an 
obvious  spinal  curvature.  But  a  careful  examination,  by  detect- 
ing the  physical  signs  of  an  aneurism,  will  generally  enable  us  to 
distinguish  the  source  of  the  trouble.  The  constant  boring  pain 
so  "much  complained  of  in  cases  of  aneurism  is  usually  thought 
to  be  due  to  absorption  of  the  vertebras ;  but,  as  Stokes  proved, 
it  has  no  necessary  connection  with  this  lesion. 

Aortic  Pulsation. — Simple  abdominal  pulsation,  such  as  we 
observe  in  hysteria,  in  dyspepsia,  and  in  pregnancy;  or  excessive 
pulsation  in  the  abdomen  due  to  an  enlarged  right  ventricle, 
or  to  insufficient  aortic  valves, — may  be  readily  mistaken  for  an 
aneurism.  But  in  the  former  case  the  history  will  generally  lead 
us  to  a  correct  conclusion,  especially  if  taken  in  connection  with 
the  facts  that  the  pulsation  is  not  heavy  and  slow,  as  in  an  aneu- 
rism, but  jerking  and  sudden ;  that  there  is  no  thrill ;  no  tumor 
with  corresponding  dulness  on  percussion,  if  we  except  pregnancy  ; 
no  systolic  murmur  audible  in  front  of  the  abdomen  or  along  the 
spine;  and  no  pain. 

The  pulsation  due  to  disease  of  the  heart  is  discriminated  by 
the  physical  signs  in  the  thorax.  Regurgitation  at  the  aortic 
orifice,  which  is  the  cardiac  affection  most  liable  to  be  confounded 
with  an  aneurism,  on  account  of  the  marked  pulsation  it  may 
occasion  in  the  left  hypochondrium  or  at  the  scrobiculus  cordis,  is 
distinguished  by  the  single  or  double  blowing  sounds,  which  are 
heard  not  only  over  the  thorax,  but  also  over  so  many  arteries  of 
the  body. 


ABDOMINAL    PULSATION.  617 

Lumbar  and  Psoas  Abscess. — In  some  cases,  soft,  fluctuating, 
deep-seated  tumors,  which  are  really  produced  by  an  aneurism, 
may  arise  in  the  lumbar  region ;  nay,  they  may  seem  to  point,  as 
happens  in  psoas  abscess,  at  Poupart's  ligament.  But,  unlike  an 
abscess,  the  effusions  of  blood  give  rise,  with  rare  exceptions,  to 
impulse  and  to  murmur. 

Non-aneurismal  Pulsating  Tumors. — When  a  tumor  of  any 
kind  presses  upon  the  aorta,  a  distinct  pulsation  is  communicated, 
which  is  apt  to  be  mistaken  for  an  aneurism  ;  and  the  similarity 
to  this  is  heightened  by  the  circumstance  that  the  morbid  growth 
may  produce  a  murmur.  The  tumors  which  most  usually  occasion 
the  phenomena  mentioned  are :  enlargement  of  the  left  lobe  of  the 
liver,  cancer  of  the  pylorus,  disease  of  the  pancreas,  or  of  the 
omentum  or  the  mesentery,  and,  in  rarer  instances,  enlargement 
and  distention  of  the  kidney,  fsecal  accumulations,  and  cancer  of 
the  lumbar  glands. 

Now,  to  avoid  error,  we  must  pay  close  attention  to  the  history 
of  the  disorder;  we  must  trace,  by  percussion,  the  outline  of  the 
solid  mass,  and  see  if  it  correspond  with  any  viscus ;  we  must  lay 
stress  on  the  presence  of  digestive  disorders,  and  on  the  amount 
of  constitutional  disturbance, — both  of  which  are  so  slight  in  ab- 
dominal aneurism ;  we  must  examine  the  urine  carefully,  and 
find  out  whether  there  are  renal  symptoms  in  the  case.  Then,  in 
non-aneurismal  tumor  the  patient  has  almost  always  been  in  bad 
health  before  the  tumor  is  detected,  and  the  swelling  rarely  causes 
pain  of  such  severity  as  is  observed  in  an  aneurism ;  moreover, 
the  transmitted  aortic  impulse  is,  as  a  rule,  lessened  by  placing 
the  patient  on  his  hands  and  knees,  thus  taking  away  the  pressure 
from  the  artery.  A  varicose  state  of  the  epigastric  veins  and  the 
existence  of  ascites  will  also  decide  against  an  aneurism;  while, 
on  the  other  hand,  the  lateral  as  well  as  the  forward  direction  of 
the  impulse,  violent  neuralgic  pains  in  the  loins  or  shooting  down 
the  back,  and  an  immovable  tumor,  are  in  its  favor.  Still,  there 
are  cases  in  which  a  morbid  growth  lying  across  the  aorta  occa- 
sions symptoms  so  nearly  like  those  of  an  aneurism  that  the  most 
skilful  diagnostician  finds  himself  at  a  loss. 

In  these  remarks  on  abdominal  aneurism  it  has  been  assumed 
that  well-defined  physical  signs  are  always  present.  But  there 
are  cases  in  which  the  physical  signs  are  obscure  or  absent,  and  in 


618  MEDICAL,    DIAGNOSIS. 

which  an  aneurism  affords  no  indication  of  its  existence,  beyond, 
perhaps,  pain.  Under  these  circumstances  we  may  suspect  the 
occurrence  of  the  affection,  but  we  cannot  be  certain  of  it. 

But  supposing  that,  from  the  combination  of  the  physical  signs 
and  symptoms,  we  are  certain  that  we  are  dealing  with  an  ab- 
dominal aneurism,  can  we  be  sure  that  it  is  aortic?  We  cannot; 
for,  although  this  is  generally  its  seat,  an  aneurism  of  the  splenic 
or  the  cseliac  artery,  of  the  superior  mesenteric  artery,  or  of  the 
renal  artery,  may,  as  far  as  the  collected  cases  enable  us  to  judge, 
produce  the  same  phenomena.* 

When  an  aneurism  bursts,  it  gives  rise  to  symptoms  which  vary 
much  with  the  seat  of  the  rent.  The  blood  is  often  effused  behind 
the  peritoneum  or  into  it.  Death  may  not  follow  for  several  days; 
but  usually  great  tenderness  of  the  abdomen  and  changes  in  the 
physical  signs  are  at  once  produced  by  the  accident. 

*  See  Ballard,  Physical  Diagnosis  of  Diseases  of  the  Abdomen,  p.  217. 


CHAPTER  VII. 

ON   THE  TJKINE,   AND   ON   DISEASES   OF   THE   TJKINAKY 

OKGANS. 

Before  discussing  the  diseases  of  the  urinary  organs  with 
which  the  practitioner  of  medicine  has  to  deal, — mainly  those  of 
the  kidney, — I  shall  briefly  notice  the  urine  in  its  pathological  and 
clinical  aspects. 

URINE. 

The  main  function  of  the  kidneys  is  to  remove  water  and  nitro- 
gen from  the  system,  at  the  same  time  that  they  take  from  the 
blood  many  of  its  salts.  The  excreted  liquid  contains,  therefore, 
a  variety  of  elements,  and  by  its  study  we  are  enabled  to  arrive 
not  only  at  the  condition  of  the  organ  which  prepares  it,  but  also 
at  the  state  of  the  circulating  fluid,  and  often  indirectly  at  that 
of  several  viscera,  the  disorders  of  which  give  rise  to  impurities 
in  the  blood,  which  the  kidneys  endeavor  to  eliminate.  Hence 
the  urine,  besides  being  the  most  accurate  index  of  the  condition 
of  the  urinary  organs,  becomes  a  fair  indication  of  that  of  many 
of  the  more  important  secreting  glands  in  the  body ;  and,  further, 
though  to  a  less  extent,  it  throws  light  on  the  workings  of  the 
nervous  system. 

But  to  glean  the  full  benefit  from  an  analysis  of  the  urine,  we 
must  be  acquainted  with  its  complex  composition  ;  explore  it  not 
merely  qualitatively,  but  quantitatively,  and  examine  its  deposits 
with  the  microscope.  An  immense  field  of  useful  research  is  thus 
thrown  open,  the  limits  of  which  are  almost  daily  widening  by 
the  exertions  of  many  devoted  laborers.  Modern  chemistry  is 
especially  endeavoring  to  find  means  which  will  bring  it  within 
the  power  of  the  busy  practitioner  to  determine,  by  apt  volumetric 
processes,  the  exact  proportion  of  the  ingredients  as  accurately  and 
as  easily  as  hitherto  we  have  detected  their  presence.  But  this  is 
a  subject  which  cannot  be  more  than  indicated  in  these  pages :  in 

619 


620  MEDICAL    DIAGNOSIS. 

this  brief  inquiry,  only  such  of  these  ingenious  investigations  will 
be  noticed  as  have  furnished  results  that  may  be  made  readily 
available  for  the  exigencies  of  professional  life. 

A  few  remarks  are  necessary  as  to  the  mode  of  procedure :  we 
must  have  at  hand  test  solutions,  the  strength  of  which  is  accu- 
rately known  ;  be  provided  with  graduated  pipettes,  for  sucking 
up  and  measuring  the  fluid  to  be  examined  prior  to  its  transfer 
to  a  convenient  vessel ;  and  possess  graduated  glass  instruments, 
or  burettes,  from  which  exact  quantities  of  the  test  solutions  may 
be  dropped.  Graduated  flasks,  also,  for  the  preparation %i  the 
solutions  of  the  reagents  are  very  useful,  and  beaker  glasses  to 
hold  the  urine.  It  is  further  customary,  in  quantitative  analyses, 
to  use  the  French  system  of  measures,  and  to  employ  instruments 
on  which  cubic  centimetres  are  marked.  One  thousand  cubic 
centimetres  are  equal  to  a  thousand  millilitres,  or  one  litre,  or 
2.1  pints,  or  to  a  thousand  grammes  of  water;  and  one  gramme  is 
equal  to  15.434  troy  grains;  one  centigramme  to  .1543  of  a  grain. 

Urine,  in  its  healthy  state,  is  of  acid  reaction,  of  amber-yellow 
color,  and  of  specific  gravity  of  1018  to  1020  as  compared  with 
distilled  water  at  1000.  On  standing  from  eight  to  twelve  hours,  a 
slight  cloudy  deposit  takes  place,  consisting  mainly  of  mucus  and 
of  epithelial  cells  from  the  urinary  passages,  and  of  a  few  crystals. 

The  manner  of  obtaining  a  specimen  of  urine  is  not  unimpor- 
tant. We  should  instruct  our  patient,  as  is  so  strongly  recom- 
mended by  Sir  Henry  Thompson,*  to  pass  the  first  two  ounces 
into  one  vessel,  and  the  remainder  into  another.  We  thus  procure 
a  specimen  of  the  renal  secretion,  in  addition  to  anything  in  the 
bladder,  separate  from  any  urethral  products,  and  avoid  the  error 
of  confounding  prostatic  or  urethral  with  vesical  or  renal  disease. 
When  it  is  essential  to  obtain  a  specimen  of  urine  absolutely  pure, 
and  unmixed  with  products  of  the  bladder,  the  same  authority 
recommends  the  drawing  off  of  the  urine  by  means  of  a  soft  gum 
catheter,  while  the  patient  is  standing.  The  bladder  should  then 
be  carefully  washed  out  by  repeated  one-ounce  injections  of  warm 
water.  The  urine  is  now  to  be  permitted  to  pass,  as  it  will  do, 
drop  by  drop,  into  a  small  glass  vessel.  The  bladder  contracts 
around  the  catheter,  and  the  urine  percolates  direct  from  the  ure- 

*  Clinical  Lectures  on  Diseases  of  the  Urinary  Organs. 


THE  URINE  AND   DISEASES  OF  THE  URINARY  ORGANS.       621 

ters,  through  their  virtual  prolongation, — the  catheter, — into  the 
receptacle.  The  urine  passed  in  the  morning,  immediately  after 
rising,  will  be  found  to  represent  with  sufficient  accuracy  the  gen- 
eral process  of  disassimilation  ;  but  if  greater  accuracy  be  desirable, 
a  specimen  of  the  mixed  urine  of  the  twenty-four  hours  should  be 
used. 

The  quantity  of  urine  daily  voided  is,  at  a  low  estimate,  forty 
ounces;  Vogel  places  it  at  fifty -seven  ounces.  Becquerel  states 
the  diurnal  average  to  be  in  men  forty-four,  and  in  women  forty- 
seven  ounces.  Hofmann  and  Ultzmann,*  and  other  recent  ob- 
servers, determine  the  mean  average  of  healthy  persons  to  be  1500 
cubic  centimetres,  about  fifty  fluidounces.  In  summer,  when  the 
skin  is  acting  freely,  less  fluid  passes  off  by  the  kidneys  than  in 
winter.  The  more  liquid  that  is  taken  into  the  system,  the  greater 
is  the  secretion  of  urine,  unless  the  other  organs  which  eliminate 
water,  as  the  skin,  lungs,  and  intestines,  are  excreting  with  un- 
wonted activity. 

The  quantity  is  diminished  in  all  cases  of  increased  specific 
gravity,  with  the  exception  of  diabetes;  it  is  diminished  in  acute 
diseases,  in  fevers,  in  cholera,  and  in  the  early  stages  of  dropsies ; 
in  some  forms  of  Bright's  disease  through  their  entire  course; 
and  for  the  most  part  in  the  last  stage  of  all  forms.  It  is,  on  the 
other  hand,  augmented  in  all  cases  of  diminished  specific  gravity  ; 
in  hysteria;  in  the  atrophic,  nodular  kidney,  in  the  contracted 
kidney,  and  in  waxy  disease.  In  almost  all  vesical  and  kidney 
affections  frequent  micturition  is  a  marked  symptom ;  not  always, 
however,  associated  with  increased  quantity  of  urine. 

The  ingredients  of  urine  are  very  various.  The  principal  are : 
urea,  the  alkaline  sulphates,  the  phosphates,  uric  acid  and  the 
urates,  the  chlorides,  kreatinine,  hippuric  acid,  mucus,  coloring- 
matter,  and  a  large  proportion  of  water. 

Yet  it  is  requisite  not  only  to  be  aware  of  the  ingredients,  but 
also  to  know  the  quantity  of  each  ingredient  commonly  present  in 
healthy  urine.  Here  is  Lehmann's  analysis  of  1000  parts,  and 
side  by  side  with  it  Thudichum's  elaborate  estimate  of  the  compo- 
sition of  the  urine  passed  within  twenty-four  hours,  the  average 
quantity  being  1400  to  1600  cubic  centimetres,  the  average  specific 

*  Analysis  of  the  Urine.     Translated.     New  York,  1879. 


622 


MEDICAL    DIAGNOSIS. 


gravity  1.020,  the  minor  estimates  accounting  for  48  out  of  55 
grammes  of  solids,  the  larger  for  62  out  of  66  grammes : 


, Lehmann N 

Water 932.019 

Solid  matter 67.981 

Urea 32.909 

Uric  acid 1.098 

Lactic  acid  ......       1.513 

Lactates 1.732 

Water  extract 632 

Spirit  and  alcohol  extract  .     10.872 
Chloride  of  sodium,  \        „  710 

Chloride  of  ammonium,  J 
Alkaline  sulphates    .     .     .       7.321 
Phosphate  of  sodium     .     .       3.989 
Phosphates  of  lime,  \  -,  iqq 

and  magnesium,     1 
Mucus 110 


-Thtjdichum- 


55  to  66 


Water      .     .     1345  to  1534  grammes. 

Mean  amount  of) 
solids,  J 

Urea  ....  30  to  40  " 
Uric  acid.  ...  0.5  " 
Kreatine  ....  0.3  " 
Kreatinine  .  .  .  0.45  " 
Xanthine-like  alkaloid    ~|  Undeter- 


Eeducine,  J     mined. 

Hippuric  acid     .     .     0.5  gramme. 

Acetic  acid    .     .     .     0.288     " 

Formic  acid  .     .     .     0.05       " 

Kryptophanic  acid.     0.65       " 

Carbonic  acid     .     .  Undetermined. 

Chlorine    ....  6  to  8  grammes. 

Chlorides  of  sodium 
and  potassium    10  to  13        " 

Sulphuric  acid    .    1.5  to  2.5    " 

Other  sul-  -v  Containing  up  to  0.2 
phuriccom-  >  gramme  of  sulphur 
pounds,         J    in  24  hours. 

Phosphoric  acid       .  3.66  grammes. 

Potassium,  Sodium.  Undetermined. 

Calcium  oxide    .     .0.17  gramme. 

Magnesium  oxide    .  0.19  " 

Earthy  phosphates  .  1.28         " 

Iron Undetermined. 

Ammonia  ....     0.7  gramme. 

Biliary  acids  .     .     .0.012         " 

Trimethylamine, 

Dinitrogenized  derivate 
of  sarcolactic  acid, 

Indigogen, 

Urrhodinogen, 

Phenol-producing   sub- 
stance, Undeter- 

Cresol-producing      sub-        mined, 
stance, 

Chromogen  of  urobilin, 

Omichmyl  oxide, 

Urochrome, 

Oxaluric  acid, 

Oxalic  acid, 


THE  URINE  AND   DISEASES  OF  THE  URINARY  ORGANS.       623 

Some  of  these  constituents  are  derived  entirely  from  the  food, 
others  from  the  metamorphosis  of  the  tissues.  Hence  we  find 
them  in  the  urine  in  increased  or  diminished  quantities,  as  a 
greater  or  smaller  supply  enters  the  body,  and  according  to  the 
activity  of  the  process  of  nutrition.  Their  amount  is  further  in- 
fluenced by  the  power  of  elimination  of  the  kidneys  and  the  pro- 
portion excreted  by  the  skin,  lungs,  and  intestines. 

Besides  the  elements  mentioned,  the  quantities  of  which  it  is 
evident  must  fluctuate  much  when  the  system  is  deranged,  we 
meet,  in  morbid  states,  with  substances  that  do  not  exist  at  all  in 
healthy  urine,  or  the  presence  of  which  is  doubtful,  such  as  albu- 
men, sugar,  blood,  bile,  fats,  oxalate  of  lime,  and  certain  pigments. 
Most  of  these  are  dissolved  in  the  urine,  and  are  not  to  be  detected 
except  by  chemical  tests ;  others  form  in  sediments  after  the  urine 
has  been  discharged,  and  may  be  at  once  recognized  by  the  micro- 
scope. 

Having  thus,  in  a  general  manner,  mentioned  the  constituents 
of  the  urine,  normal  and  accidental,  let  us,  in  the  same  general 
manner,  look  at  the  points  of  clinical  interest  to  be  decided  by 
an  analysis ;  in  other  words,  let  us  ascertain  what  the  physician, 
not  the  professed  chemist,  is  in  quest  of.  And  here  it  may  be 
stated  that  we  are  always  somewhat  guided  by  our  knowledge 
of  the  case.  We  should,  for  instance,  be  most  likely  to  look  for 
albumen  in  dropsical  affections;  or  for  sugar  where  a  large  quan- 
tity of  urine  was  habitually  passed. 

Usually,  we  endeavor  to  fix  all  of  these  waymarks :  the  spe- 
cific gravity,  the  color,  the  quantity,  the  reaction,  the  presence 
or  absence  of  such  important  abnormal  ingredients  as  albumen 
and  sugar,  and  the  character  of  the  deposits.  Frequently,  too,  we 
extend  our  examination  until  we  have  determined  approximately, 
if  not  accurately,  the  increase  or  diminution  of  the  main  constit- 
uents of  the  urine,  especially  of  the  urea,  uric  acid,  chlorides, 
phosphates,  and  sulphates,  and  the  distribution  or  non-distribution 
of  bile  and  other  unusual  constituents  through  the  fluid.  Let  us 
examine  these  points  more  in  detail. 

Color. — The  color  of  the  urine  is  much  affected  by  food  and 
medicine,  as  well  as  by  various  morbid  processes;  so  rapidly, 
indeed,  affected,  that  we  must  be  chary  of  drawing  conclusions 
from  the  appearance  of  the  secretion  alone.     Yet  we  suspect  the 


624  MEDICAL    DIAGNOSIS. 

presence  of  certain  substances,  or  are  nearly  positive  of  their 
absence,  by  the  appearance  of  the  fluid.  Thus,  a  smoky  or  a  red 
aspect  is  apt  to  be  owing  to  admixture  of  blood ;  a  very  light 
color  denotes  generally  an  increase  of  water,  and  is  commonly 
found  in  diabetes,  in  hysteria,  and  in  kindred  nervous  affections. 
It  is  never  met  with  in  febrile  diseases,  for  the  urine  of  persons 
suffering  from  fever  is  of  dark  hue.  A  greenish-yellow  or  brown- 
ish tint  of  the  discharge  is  indicative  of  bile;  but  a  similar  tinge 
may  be  present  when  rhubarb  has  been  taken.  A  dirty  blue  urine 
happens  from  an  indigo  sediment;  it  is  alkaline,  and  occurs  chiefly 
in  typhus  and  in  cholera.  Strong  coffee  darkens  the  urine;  tur- 
pentine darkens  and  imparts  a  violet  odor  to  it;  carbolic  acid,  tar, 
and  creasote  render  it  black ;  so  do  disintegrated  blood  and  mel- 
anotic cancer.  Santonin,  logwood,  and  senna  discolor  it.  The 
first-named  substance  gives  it  a  bright  yellow  color,  which  on  the 
addition  of  an  alkali  becomes  crimson.*  Senna  may  impart  to  it 
a  brownish  or  a  deep  red  color,  which,  however,  like  that  due  to 
rhubarb,  is  lightened  on  the  addition  of  mineral  acids,  and  is  thus 
distinguished  from  the  hue  of  urine  containing  blood. 

The  altered  appearance  is  mostly  due  to  the  coloring-matter  of 
these  articles  being  excreted  with  the  urine.  But  an  unnatural 
hue  is  owing  to  a  change  in  the  normal  coloring-matter.  This 
pigment  consists  of  a  substance  called  urophsein,  or  urohcematin, 
bearing  a  close  relation  to  the  pigment  of  the  blood,  and,  like  it, 
containing  iron.  It  is,  indeed,  regarded  by  Harley  as  arising  from 
the  destruction  qf  the  red  blood  corpuscles.  Its  presence  may  be 
demonstrated  by  adding  double  the  quantity  of  strong  sulphuric 
acid  to  urine,  which  assumes  a  decidedly  brown  tint.  If  it  be- 
come very  dark,  and  do  not  contain  sugar  or  bile,  we  may  infer 
that  the  quantity  of  the  urohsematin  is  increased,  which  is  the  case 
in  pyrexias  and  in  affections  of  the  liver.  Urohsematin  may  be 
present  in  excess  in  pale  urine,  f  But  urohaematin  is  no  longer 
regarded  by  most  eminent  chemists  as  the  characteristic  pigment, 
but  as  a  mere  modification  of  urobilin,  itself  a  reduction  product 

*  Smith,  Dublin  Quarterly  Journal,  Nov.  1870. 

f  According  to  Schunck  (Proceedings  of  the  Royal  Society,  vol.  xvi.  p.  73 
et  seq.),  the  color  of  normal  urine  is  due  not  to  one  substance,  but  to  two 
distinct  and  peculiar  pigments;  one,  urian,  soluble  in  alcohol  and  ether, 
the  other,  urianine,  soluble  in  alcohol,  but  insoluble  in  ether. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.      625 

of  the  coloring-matter  of  the  bile,  bilirubin.  Urobilin  is  then 
the  chief  pigment  of  urine.  Urine  moderately  rich  in  it  shows, 
on  addition  of  ammonia  and  a  little  chloride  of  zinc  solution, 
a  green  fluorescence,  and  in  the  spectrum  a  dark  absorption  band 
between  Fraunhofer's  lines  b  and  F. 

A  method  for  estimating  the  quantity  of  the  pigment  has  been 
proposed  by  Vogel.*  It  consists  in  comparing  the  hue  of  the 
urine  with  a  table  of  fixed  colors,  each  shade  of  which  represents 
a  definite  proportion  of  pigment. 

There  are,  moreover,  pigments  developed  in  the  urine,  owing 
to  the  decomposition  of  substances  pre-existing  in  that  fluid. 
For  instance,  indican  does  not  itself  impart  any  color  to  the  urine, 
but  by  its  decomposition,  to  which  it  is  prone,  yields  indigo-blue, 
indigo-red,  and  glucose.  Schunckf  finds  it  as  a  normal  constituent 
of  the  urine,  and  Carter^  gives  the  following  test  for  its  detection. 
Into  a  test-tube  pour  urine  to  the  depth  of  half  an  inch ;  to  this 
add  one-third  of  its  volume  of  commercial  sulphuric  acid  of  the 
sp.  gr.  1830,  by  allowing  it  to  trickle  down  the  side  of  the  tube. 
The  fluids  should  then  be  intimately  mixed  by  agitating  them 
together,  and,  according  to  the  amount  of  indican  present,  a  color 
is  produced  varying  from  the  faintest  tinge  of  pink  or  lilac  to 
the  deepest  indigo-blue.  A  tolerably  correct  estimate  of  the  share 
taken  by  the  different  coloring-matters  in  the  production  of  a  given 
tint  may  be  made  by  neutralizing  the  sulphuric  acid,  added  as 
above,  with  caustic  ammonia,  then  agitating  the  mixture  with 
one-third  of  its  volume  of  ether,  and  allowing  it  to  remain  at 
rest  for  a  few  minutes.  The  ether  rises  to  the  surface,  holding  the 
indigo-red  in  solution,  and  the  blue  in  suspension, — if  any  have 
been  generated, — leaving  the  ordinary  urine-pigment  dissolved  in 
the  aqueous  fluid  below.  Another  method  for  an  approximate 
quantitative  determination  is  that  of  Senator,  in  which,  after  hy- 
drochloric acid,  a  saturated  solution  of  hypochlorite  of  calcium  is 
used,  and  subsequently  chloroform,  the  color  being  more  or  less 
deep  according  to  the  amount  of  indican  present.§     Heineman 

*  Neubauer  and  Vogel,'  "  Anleitung,"  etc.  Translation  of  7th  edition. 
New  York,  1879. 

f  Philos.  Mag.,  Aug.  1857.  %  Edinb.  Med.  Journ.,  Aug.  1859. 

|  Centralblatt  fur  d.  Med.  Wiss.,  1877,  quoted  in  Boston  Medical  and  Sur- 
gical Journal,  1879. 

40 


626  MEDICAL    DIAGNOSIS. 

modifies  the  test  by  adding  the  chloroform  after  the  acid  lias  been 
added.*  For  more  accurate  estimation  of  indican,  Jaffe's  method 
is  the  best,  or  that  of  Weber,  f 

There  is  little  doubt  that  a  number  of  the  coloring-matters 
mentioned  as  present  in  the  urine  are  produced  by  spontaneous 
decomposition  of,  or  by  the  action  of  agents  on,  substances,  either 
colored  or  colorless,  existing  in  the  urine.  Schunck  has  already 
proved  the  identity  of  indican  and  the  products  of  its  oxidation, 
indigo-blue  and  indigo-red,  with  the  uroxanthin  of  Heller,  and 
the  products  of  its  decomposition,  uroglaucin  and  urorrhodin. 
Thudichum  considers  that  normal  urine  contains  only  one  yellow 
coloring-matter,  urochrom,  and  that  uroglaucin,  urohsematin,  and 
the  other  pigments  mentioned  are  mixtures  of  its  decomposition. J 
But  urochrom  itself  is  regarded  by  some  as  modified  urobilin. 

Indican,  or  uroxanthin,  as  Heller  describes  it,  is  readily  detected 
by  dropping  twenty  to  thirty  drops  of  urine  on  at  least  five  or  six 
times  as  much  strong  hydrochloric  or  nitric  acid.  After  the  fluid 
has  been  agitated  for  some  time,  it  becomes  red  or  faintly  violet ; 
and  if  it  contain  more  than  a  very  small  quantity  of  uroxanthin, 
it  assumes  a  decidedly  violet  or  blue  color.  This  pigment  is  in 
composition  closely  allied  to  hsematin  and  to  the  coloring-matter 
of  the  bile.  It  is  now  supposed  to  be  indol,  which,  uniting  with 
a  saccharine  substance,  is  eliminated  with  the  urine  as  indican. 
It  is  noticed  in  considerable  excess  in  very  concentrated  urine,  and 
in  affections  of  the  nervous  system,  of  the  serous  membranes,  and 
in  granular  kidneys.  When  we  have  evidences  of  cancer,  its  pres- 
ence in  large  quantities  in  the  urine,  Xeftel  tells  us,  is  conclusive 
of  cancer  of  the  liver.  Rosenstein  found  it  enormously  increased 
in  Addison's  disease,  and  JafTe  in  intestinal  obstruction,  especially 
of  the  small  intestine.  In  pernicious  anaemia  there  is  also  a  large 
increase  of  indican. § 

Of  the  pathological  coloring-matters  peculiar  to  the  urine,  the 
purple  or  pinkish,  the  uroerythrin  of  Heller,  the  purpurin  of 
Bird,  is  the  most  common.  It  has  a  strong  affinity  for  uric  acid 
and  the  urates,  and  stains  their  deposit  deep  red   or  pink.     It 

*  See  Xeubauer  and  Vogel,  op.  cit. 
f  Archives  of  Medicine,  New  York,  August,  1880. 
1  Pathology  of  the  Urine,  2d  edit.     London,  1*77. 
£  Hennige,  Archiv  fur  Klin.  Med.,  xxii.,  1879. 


THE  URINE  AND   DISEASES  OF  THE  URINARY   ORGANS.      627 

abounds  in  the  urine  of  febrile  and  inflammatory  diseases,  and  is 
common  in  acute  rheumatism,  in  gout,  in  pyaemia,  and  in  diseases 
of  the  liver.  Its  test  is  a  solution  of  acetate  of  lead,  which  pro- 
duces a  pinkish  precipitate. 

Specific  Gravity. — We  take  the  specific  gravity  of  urine  to 
judge  of  the  solid  matter  it  contains.  The  readiest,  although  not 
the  most  exact,  means,  is  the  urinometer.  But  for  the  implement 
to  yield  trustworthy  results  the  fluid  should  be  brought  to  the 
temperature  at  which  the  urinometer  has  been  graduated, — gen- 
erally 60°  F.  A  difference  of  7°  F.  corresponds  with  about  1 
degree  of  the  urinometer.*  More  accurate  than  the  urinometer 
is  the  specific  gravity  bottle,  "  picnometer,"  or  More-Westphal's 
balance. 

If  there  be  but  a  small  quantity  of  urine  for  examination,  we 
note  the  amount  and  how  many  volumes  of  distilled  water  it  takes 
to  fill  the  vessel  to  the  height  required  to  float  the  urinometer. 
We  then  multiply  the  number  above  1000  that  the  instrument 
shows,  by  the  total  number  of  volumes  of  the  mixed  fluid. 

From  the  specific  gravity  we  may  calculate  approximately  the 
quantity  of  solid  matter  passed  by  multiplying  the  number  above 
1000  by  2  for  the  specific  gravities  below  1018,  and  by  2.33  for 
those  above.  This  may  be  done  whether  we  estimate  in  grammes 
or  grains.  For  instance,  in  urine  of  specific  gravity  of  1010  there 
will  be  20  grains  of  solid  matter  in  each  1000  grains  of  urine ;  in 
urine  of  1030,  69.90  grains.  This  information  obtained,  it  is  easy 
to  find  the  whole  amount  of  solids  contained  in  the  urine  of  twenty- 
four  hours  after  ascertaining  first  the  quantity  passed  in  that  time. 
To  take  the  first  illustration  :  if  1000  grains  yield  20  of  solid 
matter,  how  much  would  be  yielded  by  20,000  (the  quantity 
passed,  we  will  say,  in  twenty-four  hours). 

1000  :  20  :  :  20,000  :  x.     x  =  400  grains. 

This  method  is  not,  however,  very  precise ;  indeed,  where  ex- 
actness is  required,  the  urine  must  be  evaporated  until  a  dry  residue 
is  left,  which  should  then  be  carefully  weighed. 

The  amount  of  solids  in  healthy  urine  is  variously  estimated. 
Beale  places  it  approximately  at  from  800  to  1000  grains;  Hof- 
mann  and  Ultzmann  at  60  to  70  grammes,  about  920  to  1080 

*  Simon,  quoted  by  Neubauer,  op.  cit. 


(328  MEDICAL    DIAGNOSIS. 

grains ;  and  in  persons  who  are  fasting,  or  have  taken  little  food, 
as  in  fevers,  at  30  grammes  in  the  twenty-four  hours.  As  a  gen- 
eral rule,  the  proportion  is  greatest  in  persons  of  heavy  weight:  if, 
therefore,  we  wish  to  make  nice  comparisons,  the  weight  of  the 
body  should  always  be  stated.  To  ascertain  how  much  of  the 
solid  matter  consists  of  the  salts,  the  organic  substances  must  be 
driven  off  at  a  red  heat. 

In  disease,  the  solids,  and  with  them  of  course  the  specific  grav- 
ity, fluctuate  very  much.  The  normal  specific  gravity  is  about 
1020.  We  find  the  specific  gravity  decidedly  increased,  rising 
to  1030  or  higher,  when  sugar  or  an  excess  of  urea  is  present, 
and  when  the  urine  is  concentrated  and  of  deep  color.  A  low  spe- 
cific gravity,  is  met  with  in  certain  forms  of  Bright's  disease,  in 
many  cases  of  hysteria,  and  in  all  pale  urines  except  that  of  dia- 
betes. But  to  be  accurate, — and,  indeed,  accuracy  in  regard  to  the 
other  physical  and  chemical  properties  is  unattainable  without  at- 
tending to  the  same  rule, — we  must  not  lay  stress  on  the  specific 
gravity  without  taking  into  account  the  measure  of  urine  passed 
in  the  twenty-four  hours,  as  well  as  the  quantity  of  drink  and  of 
food  swallowed;  all  of  which  of  necessity  influences  the  specific 
gravity.     So,  too,  does  the  activity  of  the  tissue-metamorphosis. 

Reaction. — Healthy  urine  reddens  blue  litmus-paper.  The 
acidity  depends  chiefly  upon  acid  salts,  especially  upon  the  acid 
phosphate  of  sodium,  although  the  recent  investigations  of  Thudi- 
chum  attribute  it  to  a  free  acid  discovered  by  him, — kryptophanic 
acid.  The  degree  of  acidity  is,  even  in  health,  not  always  equal,  and 
is  much  influenced  by  digestion.  If  no  food  have  been  taken  for 
hours,  the  discharge  is  highly  acid  ;  that  passed  after  a  meal,  and 
while  the  process  of  digestion  is  going  on,  is  but  faintly  so,  or 
neutral,  or  even  alkaline.  In  about  three  or  four  hours  after 
meals  the  alkaline  tide  turns,  and  the  acidity  of  the  urine  slowly 
increases  until  food  is  again  taken.  There  seems,  however,  to  be 
a  limit  to  the  increase  of  acidity,  for  Bence  Jones  found  that  con- 
tinuing: to  fast  for  twelve  hours  beyond  the  usual  meal-time  did 
not  intensify  the  acidity  of  the  urine.  The  alkalinity  of  the  urine 
after  meals  is  rarely  detected  at  the  bedside.  For,  although  the 
urine  may  be  alkaline  when  secreted  by  the  kidneys,  it  is  generally 
mixed  in  the  bladder  with  that  which  collected  before  or  after  the 
alkaline  tide,  and  the  mixed  urine  when  passed  may  have  an  acid 


THE  L'RIXE   AXD  DISEASES  OF  THE  URINARY  ORGAXS.     629 

reaction.  Roberts  attributes  the  occurrence  of  the  alkaline  tide 
after  meals  to  the  entrance  of  the  newly-digested  food  into  the 
blood. 

The  acidity  of  the  urine  is  augmented  by  the  administration  of 
the  vegetable  or  the  mineral  acids ;  yet  they  do  not  cause,  even  in 
large  doses,  as  great  variations  as  does  digestion.  We  find,  too, 
acidity  of  the  urine  strongly  marked  if  any  acid  be  present  in  it 
which  sets  the  uric  acid  free,  or  if  this  be  in  decided  excess.  Some 
drugs  strongly  influence  the  acidity  of  the  urine;  a  new  acid, 
urochloralic  acid,  has  indeed  been  found  in  it  after  ingestion  of 
chloral.* 

We  estimate  the  amount  of  free  acid  in  the  urine  by  a  solution 
of  sodic  hydrate  (caustic  soda),  or  by  a  solution  of  carbonate  of 
sodium,  containing  53  grammes  to  the  litre  or  530  grains  to  10,000 
grains.  Some  of  this  solution  is  added  drop  by  drop  to  100  cc. 
of  urine,  which  has  been  measured  off  in  a  beaker  glass.  After 
the  addition  of  each  half  cubic  centimetre,  a  drojD  of  the  mixture 
is  placed,  by  means  of  a  glass  rod,  on  well-prepared  litmus- paper. 
When  the  paper  is  no  longer  reddened,  the  analysis  is  finished;  and 
by  noting  how  much  of  the  standard  solution  has  been  used,  we 
can  determine  the  acidity  of  the  urine,  which  it  is  customary  to 
express  as  equal  to  so  many  grains  of  oxalic  acid,  that  being  the 
substance  used  to  determine  the  activity  of  the  sodic  solution,  each 
cc.  of  which  must  indicate  10  milligrammes  of  oxalic  acid. 

Urine,  when  voided,  remains  ordinarily  acid  for  at  least  a  day; 
but  it  mav  lose  its  acidity  much  sooner.  This  is  alwavs  a  signifi- 
cant  fact,  having  much  the  same  meaning  as  if  the  fluid  had  been 
discharged  in  a  neutral  or  alkaline  state. 

Xow,  an  alkaline  reaction  may  result  from  several  causes  :  from 
the  effect  of  digestion,  as  already  mentioned  ;  from  the  presence  of 
a  fixed  alkali,  as  the  carbonate  of  sodium  or  of  potassium  ;  or  from 
a  volatile  alkali,  due  to  the  decomposition  of  the  urea  into  carbo- 
nate of  ammonium.  In  the  former  case,  heat  does  not  restore  the 
color  of  the  red  litmus-paper — it  remains  blue ;  in  the  latter,  a 
gentle  heat  soon  brings  back  the  original  red  tint.  Moreover,  in 
alkalescence  from  either  cause,  the  earthy  phosphates  are  precipi- 
tated, the  fixed  alkali  causing  the  precipitation  of  the  amorphous 

*  Musculus  and  Merino;.  Berichte  d.  Deutsch.  Chem.  Gesellschaft,  Bd.  viii. 


630  MEDICAL    DIAGNOSIS. 

phosphate  of  lime;  while  by  the  volatile  alkali  the  phosphates  of 
ammonium  and  magnesium,  in  conjunction  with  the  phosphate  of 
calcium,  are  thrown  down,  and  the  triple  phosphate  is  abundantly 
formed,  and  can  be  easily  recognized  under  the  microscope  by  its 
beautiful  prismatic  crystals. 

Alkalinity  of  the  urine  from  fixed  alkali  is  not  inconsistent  with 
health.  We  have  alluded  to  the  effects  of  digestion  ;  and  alkaline 
urine  also  results  from  the  use  of  certain  articles  of  vegetable  food, 
or  of  the  salts  of  sodium  and  potassium  administered  as  medicine. 
Urine  owing  its  alkalinity  to  a  volatile  alkali,  like  carbonate  of 
ammonium,  is  always  to  be  viewed  as  pathological.  The  disturb- 
ance is  generally  long  continued,  and  the  urine  loses  its  acidity  in 
the  bladder,  in  consequence  of  a  disease  of  the  mucous  coat  of  the 
viscus,  or  from  being  long  retained  there,  as  in  cases  of  paraplegia, 
or  from  admixture  with  pus,  which  acts  as  a  kind  of  ferment  and 
leads  to  decomposition  of  the  urea. 

Changes  in  the  Quantity  of  the  more  Important  Con- 
stituents of  Urine. — Here  we  shall  have  mainly  to  investigate 
the  excess  or  deficiency  of  urea,  of  uric  acid,  the  urates,  phos- 
phates, sulphates,  and  chlorides. 

Urea. — The  amount  of  urea  excreted  by  well-nourished,  healthy, 
adult  males  in  the  twenty-four  hours  is  estimated,  in  round  numbers, 
bv  Bischoff  at  542  grain-,  by  Roberts  at  3J  grains  per  pound  weight 
of  the  body,  and  by  Neubauer  and  Vogel  at  25  to  40  grammes, 
about  385  to  640  grains,  or  0.37  to  0.60  gramme  for  every  kilo- 
gramme of  weight  of  the  body.  Thus  the  amount  is  very  varia- 
ble; yet  it  is  not  so  variable  that  a  study  of  the  quantity  may  not 
answer  useful  practical  purposes.  Urea  is  the  principal  product  of 
the  change  of  nitrogenized  substances.  Its  proportion  fluctuates, 
therefore,  with  the  food  partaken  of,  as  well  as  with  the  activity 
of  the  transformation  of  the  structures  of  the  system  :  hence  it  be- 
comes the  most  important  index  of  the  waste  and  repair  of  tissues. 
Exertion  of  body  and  of  mind  leads  to  the  discharge  of  a  larger 
quantity  of  urea.  If  this  be  replaced  by  a  nourishing  diet,  no- 
thing is  lost ;  the  body  retains  its  health.  But  when  the  requi- 
site amount  of  nitrogenized  aliment  is  not  taken,  or,  if  taken, 
cannot  be  assimilated,  owing  to  a  disturbance  in  digestion,  the 
person  wastes.  We  notice,  too,  in  acute  febrile  states,  until  their 
height  is  reached,  hand  in  hand  with  the  emaciation,  an  increase 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.       631 

of  this  significant  urinary  constituent,* — a  proof,  then,  of  the  rapid 
and  unsupplied  disintegration  of  the  tissues.  We  see  the  same  in- 
crease during  paroxysms  of  intermittent  fever,  in  inflammations, 
and  in  some  cases  of  nervousness ;  also  frOm  a  predominant  animal 
diet,  and  in  certain  forms  of  indigestion,  in  which  the  food  is 
speedily  passed  off  in  the  shape  of  urea  instead  of  acting  its  part 
in  the  nutrition  of  the  economy. 

A  lessened  quantity  of  urea  is  excreted  during  fasting,  from 
an  almost  exclusive  vegetable  diet,  in  dropsies,  and  in  many  long- 
continued  organic  diseases  which  gradually  undermine  the  general 
nutrition  and  diminish  tissue-change;  but  the  diminished  amount 
in  the  urine  may  also  be  due  to  a  want  of  secreting  power  of  the 
kidneys.  The  urea,  or  the  products  of  its  decomposition,  then,  act 
as  a  poison  in  the  blood;  and  headache,  nausea,  convulsions, — in 
fact,  the  train  of  symptoms  classed  as  ursemic  poisoning, — are  en- 
countered. Urea  is  sometimes  not  found  in  the  urine  at  all,  or 
only  in  traces,  having  been  replaced,  as  Frerichs  tells  us,  by  leucine 
and  tyrosine. 

There  are  several  tests  for  urea.  Liebig's  process  is  based  on 
the  fact  that  if  bichloride  of  mercury  in  solution,  and  bicarbonate 
of  potassium  in  excess,  be  added  to  a  solution  of  urea,  we  obtain 
a  compound  of  urea  and  mercury  which  is  perfectly  insoluble  in 
water.  The  method  of  procedure  is  thus  given.  First  separate 
the  phosphoric  acid.  This  is  accomplished  by  measuring  off  with 
a  pipette  40  cc.  of  urine,  and  adding  20  cc.  of  a  baryta  solu- 
tion, obtained  by  mixing  one  volume  of  a  solution  of  nitrate  of 
barium  with  two  volumes  of  a  caustic  baryta  solution,  both  pre- 
pared by  cold  saturation.  The  precipitate  is  separated  by  filtra- 
tion; and  15  cc.  (corresponding  to  10  cc.  of  the  urine)  of  the 
filtered  fluid  are  placed  in  small  beakers  for  each  analysis.  To 
this  quantity  of  urine  a  solution  of  nitrate  of  mercury  of  known 
strength  (and  the  strength  recommended  is  that  20  cc.  of  the 
solution  exactly  suffice  for  the  precipitation  of  the  urea  in  10  cc. 

*  liosenstein,  in  his  researches  on  the  excretion  of  urea  in  exanthematous 
typhus,  found  that,  in  the  beginning,  the  quantity  eliminated  with  the  urine 
is  remarkably  increased,  and  then,  according  to  the  previous  mode  of  living 
of  the  individual,  sooner  or  later  sinks,  with  simultaneous  increase  of  the  fever, 
to  far  beneath  the  normal  standard,  rising  again  with  the  augmented  ingestion 
of  food.     Medical  Times  and  Gazette,  1869,  vol.  i.  p.  90. 


632  MEDICAL    DIAGNOSIS. 

of  a  standard  solution  of  urea,  in  which  this  quantity  contains 
precisely  200  milligrammes  of  urea)  is  added  by  a  pipette  or  from 
the  burette  in  very  small  quantities,  the  mixture  being  constantly 
stirred.  When  no  further  precipitation  or  turbidity  is  observed, 
a  few  drops  of  the  mixture  are  placed  by  means  of  a  glass  rod  on 
a  watch-glass,  and  some  drops  of  a  solution  of  carbonate  of  sodium 
are  brought  in  contact  with  them.  As  long  as  the  fluid  in  the 
watch-glass  retains,  even  for  some  seconds,  its  white  color,  it  still 
contains  free  urea ;  and  more  of  the  test  solution  of  the  mercury 
must  be  dropped  into  the  beaker,  until,  on  a  renewal  of  the  test  in 
the  watch-glass,  a  distinct  yellow  color  becomes  instantly  apparent. 
The  amount  of  urea  is  now  calculated  from  the  quantity  of  the 
mercurial  solution  employed:  first  we  find  how  much  the  10  cc. 
of  urine  contained,  and  then  the  total  discharge  in  the  urine  passed 
in  twenty-four  hours  is  readily  determined.  When  albumen  is 
present,  it  has  first  to  be  coagulated  by  exposure  to  heat,  and  the 
fluid  carefully  filtered,  before  the  amount  of  urea  can  be  ascer- 
tained ;  and  the  process  also  requires  modification  and  correction  if 
the  urine  contain  more  than  one  and  a  half  per  cent,  of  chloride  of 
sodium  or  carbonate  of  ammonium. 

An  easier  method  is  Davy's,  with  the  hypochlorite  of  sodium  or 
Labarraque's  solution,  which  with  the  imported  French  solution, 
Austin  Flint,  Jr.,  states,*  is  all  that  can  be  desired.f  The  process 
is  as  follows.  A  strong  glass  tube,  with  a  bore  not  larger  than  the 
thumb  can  conveniently  cover,  twelve  or  fourteen  inches  in  length, 
closed  at  one  end  and  ground  smooth  at  the  other,  capable  of 
holding  from  two  to  three  cubic  inches,  and  graduated  into  tenths 
and  hundredths  of  a  cubic  inch,  is  filled  more  than  a  third  full  of 
mercury,  to  which  afterward  is  added  a  measured  quantity,  from  a 
quarter  of  a  drachm  to  a  drachm,  of  the  urine  to  be  examined. 
The  tube  is  then  to  be  exactly  filled  with  a  solution  of  hypochlorite 
of  sodium  (Labarraque's  solution).  The  mouth  of  the  tube  is  then 
instantly  tightly  covered  with  the  thumb,  inverted  once  or  twice 
to  mix  the  urine  with  the  hypochlorite,  and  finally  placed  beneath 
a  saturated  solution  of  salt  in  water  contained  in  a  cup.  The 
mercury  then  flows  out,  and  the  solution  of  common  salt  takes  its 

*  Chemical  Examinations  of  the  Urine,  p.  46. 

f  Fowler  and  PifFard  find  the  liquor  soda?  chlorinataj  of  Squibb  equally 
trustworthy.     Piffard,  Guide  to  Urinary  Analysis,  p.  37. 


THE  URINE  AND   DISEASES   OF  THE  URINARY  ORGANS.      633 

place;  the  mixture  of  urine  and  hypochlorite,  being  lighter  than 
the  solution  of  salt,  remains  in  the  upper  part  of  the  tube.  De- 
composition of  the  urine  soon  takes  place ;  bubbles  of  nitrogen 
escape,  and  collect  in  the  upper  part  of  the  tube.  When  decom- 
position is  complete,  which  is  known  by  the  cessation  of  the  evo- 
lution of  bubbles  of  gas,  the  quantity  collected  is  read  off  the  scale 
on  the  tube.  When  great  accuracy  is  required,  corrections  must 
be  made  for  temperature  and  atmospheric  pressure.  Each  cubic 
inch  of  gas  represents  0.645  of  a  grain  of  urea.  Several  of  the  sub- 
stances found  in  urine  during  disease,  as,  for  example,  sugar,  albu- 
men, biliary  ingredients,  and  excess  of  urinary  coloring- matter, 
produce  scarcely  any  effect  on  the  results  obtained  by  this  method.* 

A  simple  but  accurate  process  for  estimating  urea  has  been  re- 
cently proposed  by  Russell  and  West,f  and  is  adopted  by  Roberts. 
It  consists  in  employing  a  solution  of  hypobromite  of  sodium  in 
an  excess  of  caustic  soda,  and  an  apparatus  with  a  measuring-tube. 
Sugar  does  not  interfere  with  the  reaction,  and  albumen  not  greatly. 
The  volume  of  nitrogen  discharged  is  the  measure  of  the  urea. 
Hypobromite  of  sodium  is  also  used  in  the  Knop-Hufner  method. J 

Another  method  for  fixing  the  quantity  of  urea  approximately 
is  that  proposed  by  Haughton.§  It  consists  in  the  use  of  tables 
showing  how  many  grains  of  urea  are  excreted  in  the  urine,  of 
which  the  amount  daily  passed  and  the  specific  gravity  are  pre- 
determined. Ou  the  following  page  is  the  table,  as  abridged  by 
Roberts.  It  can,  for  practical  purposes,  be  depended  on,  except 
when  sugar  and  albumen  are  present. 

A  rough  way  of  estimating  the  urea  is  to  drop  nitric  acid  into 
a  porcelain  capsule  holding  urine  which  has  been  evaporated  to  a 
mucilaginous  consistence.  Crystals  of  pearly  lustre,  in  which  the 
microscope  shows  the  characteristic  shape  of  nitrate  of  urea,||  are 
developed ;  and  by  always  evaporating  the  same  quantity  and 
using  a  capsule  of  equal  size,  we  may  judge  of  the  amount  of  the 

*  Davy,  Dublin  Hospital  Gazette,  June,  1854,  and  Philosophical  Magazine. 

f  Chemical  Society's  Journal,  Aug.  1874,  quoted  in  the  American  Journal 
of  the  Medical  Sciences,  April,  1875. 

X  Neubauer  and  Vogel,  op.  cit.,  p.  242. 

I  Medical  Times  and  Gazette,  Oct.  1864. 

||  This  shape  changes  to  pencillated  needles  when  albuminuria  exists.  Hof- 
mann,  "  Zoochemie." 


634 


MEDICAL,    DIAGNOSIS. 


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THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.      635 

important  ingredient  as  compared  with  that  contained  in  other 
specimens  of  both  normal  and  abnormal  urine.  More  accurate  is 
it,  as  Hofmann  and  Ultzmann  advise,  to  treat  the  crystals  with 
carbonate  of  barium,  and  then  to  extract  the  urea  from  the  dried 
mass  by  means  of  alcohol.  If  crystals  form  without  the  urine 
being  concentrated  by  evaporation,  simply  on  the  addition  in  the 
cold  of  about  an  equal  bulk  of  nitric  acid,  urea  is  always  in  con- 
siderable excess.  But  we  may  often,  eveu  without  subjecting  the 
fluid  to  this  test,  guess  that  the  urea  is  increased,  by  observing  the 
deep-yellow  color,  the  strong  urinous  smell,  and  the  high  specific 
gravity  of  the  discharge. 

Uric  Acid. — Uric  acid,  like  urea,  is  a  product  of  the  metamor- 
phosis of  tissue.  It  is,  indeed,  supposed  by  Liebig  that  the  acid 
is  an  early  stage  of  the  transformation  of  urea.  Hofmann  teaches 
that  uric  acid  is  deposited  owing  to  the  decomposition  of  the 
urates  by  the  acid  phosphate  of  sodium.  Under  ordinary  circum- 
stances the  deposition  of  uric  acid  occurs  subsequently  to  the  ex- 
pulsion of  the  urine  ;  but  should  the  acid  phosphate  of  sodium  be 
in  excess,  the  uric  acid  may  be  precipitated  before  the  secretion  is 
voided,  and  thus  give  rise  to  gravel  and  calculi.  This  may  also 
happen  through  too  great  concentration  of  the  urine. 

In  healthy  urine  the  presence  of  uric  acid  cannot  be  detected 
without  the  addition  of  a  strong  acid,  since  it  exists  in  the  form  of 
soluble  urates,  which  must  be  first  decomposed.  The  uric  acid  is 
gradually  thrown  down  in  small  red  grains,  which,  should  it  be 
desirable  to  determine  the  quantity  of  the  acid,  are  washed,  dried, 
and  carefully  weighed.  Where  accuracy  is  called  for,  it  is  best  to 
allow  the  acid  to  separate  at  a  low  temperature,  by  keeping  the 
fluid  in  a  cool  place  for  about  four  days,  after  acidulating  it  with 
nitric  acid  about  one  ounce  to  fifty.*  It  is  also  advisable  to  use 
always  the  same  quantity  of  urine.  Neubauer  recommends  200 
cc.  of  urine  and  5  cc.  of  hydrochloric  acid.  All  the  uric  acid 
is  not  precipitated  by  the  hydrochloric  acid,  and  Schwanert  tells 
us  that  in  every  100  cc.  of  the  mixture  of  hydrochloric  acid  and 
urine  0.0048  gramme  of  uric  acid  remains,  which  must  be  added 
to  that  directly  obtained.     Neubauer  recommends  this  correction. 


*  Lee  and  Atlee  on  Under-estiination  of  Uric  Acid,  American  Journal  of 
the  Medical  Sciences,  April,  1869. 


036 


MEDICAL    DIAGNOSIS. 


Paw*  has  recently  directed  attention  to  the  value  of  ammo- 
niated  cupric  liquid  which  he  has  introduced  for  the  determination 
of  sugar.  Uric  acid,  like  sugar,  reduces  the  oxide  of  copper,  and 
the  test  enables  us  to  estimate  the  amount  of  uric  acid  precisely 
and  easily. 

The  characteristic  reaction  of  uric  acid  is  furnished  by  the 
murexide  test.  A  few  drops  of  nitric  acid  are  mingled  with  the 
suspected  deposit  in  a  capsule,  and  the  mixture  is  slowly  evapor- 
ated nearly  to  dryness  over  a  lamp ;  a  drop  of  ammonia  is  then 
added,  which  produces  instantly  a  rich  purple, — Prout's  purpurate 
of  ammonia. 

Another  delicate  test  is  the  one  recommended  by  Harley.  A 
little  of  the  sediment  is  dissolved  in  a  solution  of  carbonate  of 
potassium  or  sodium.  A  few  drops  are  then  placed  on  paper,  and 
a  solution  of  nitrate  of  silver  added.  At  once  a  marked  gray  stain 
indicates  the  uric  acid. 

Fig.  41. 


Crystals  of  uric  acid,  magnified  about  200  diameters.     M "st  "t 
these  forms  are  seen  in  the  urine  of  acute  rheumatism. 


But  both  uric  acid  and  the  urates  can  be  much  more  easily  and 
quickly  discriminated  by  the  microscope.  The  crystals  of  uric 
acid  are  readily  discerned,  notwithstanding  that  they  vary  both 
in  size  and  in  form.  Rhombic  plates  with  rounded  angles  are 
frequent.     To   obtain  the  crystals  rapidly,   where  they  are  not 


*  Proceed.  Roy.  Soc,  vols,  xxviii.  and  xxix.     Lancet,  April,  1880. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.       637 

passed  as  uric  acid,  a  portion  of  the  suspected  deposit  is  dissolved 
in  a  drop  of  potassa,  and  the  alkaline  solution  then  treated  with 
an  excess  of  acetic  acid :  after  the  lapse  of  a  few  hours  crystals 
of  uric  acid  will  be  formed. 

In  disease,  the  fluctuations  in  the  quantity  of  uric  acid  are 
great;  as  a  general  rule,  they  correspond  to  the  rise  and  fall  of 
urea.  We  find  the  acid  diminished  in  hydruria  and  affections  in 
which  the  eliminating  power  of  the  kidneys  is  interfered  with,  as 
in  the  more  advanced  stages  of  Bright's  disease.  An  increase  is 
encountered  in  acute  inflammations,  in  fevers,  in  functional  dis- 
orders and  many  of  the  structural  affections  of  the  liver,  in  heart 
and  lung  diseases  attended  with  dyspnoea,  in  leukaemia,  and  in  acute 
rheumatism.  In  the  latter  malady  the  little  red  granules,  visible 
to  the  naked  eye,  form  a  deposit  in  the  urine  soon  after  it  is  voided. 

We  must,  however,  be  careful  not  to  suppose  the  uric  acid  to 
be  in  excess  because  it  is  readily  precipitated.  It  may  or  may 
not  be  in  larger  amount :  the  sediment  merely  proves  an  aug- 
mentation of  acidity  in  the  urine  sufficient  to  take  away  the  base 
from  the  uric  acid.  This  happens  often  as  the  result  of  acid  fer- 
mentation of  the  urine.  Frequently  urates  are  separated  along 
with  the  uric  acid;  we  find  then  generally  a  dark  urine  of  high 
specific  gravity  and  of  very  acid  reaction. 

Persons  who  habitually  pass  urine  of  the  character  described 
are  subject  to  gastric  or  hepatic  disorders.  They  are  also  often 
gouty,  or  of  lithsemic  tendencies,  and  frequently  consumers  of  a 
large  amount  of  animal  food,  or  intemperate  or  indolent  in  their 
habits.  Hence  it  is  not  uncommonly  perceived  that  exercise  in 
the  open  air,  regulating  the  diet,  attention  to  the  action  of  the 
skin,  and  the  use  of  mild  aperients,  by  tending  to  eliminate  the 
acid  and  by  keeping  the  blood  from  becoming  vitiated,  afford  more 
real  and  permanent  benefit  than  the  exhibition  simply  of  alkalies 
to  neutralize  the  acidity  of  the  urine. 

Uric  acid  or  urates  are  never  found  as  sediments  in  freshly- 
voided  healthy  urine.  Occasionally  precipitates  of  uric  acid  or 
urates  occur  in  the  urinary  passages.  Now,  these  sediments  may 
concrete  and  form  the  nuclei  of  calculi ;  or  they  may  be  passed  in 
small  particles,  commonly  spoken  of  as  "gravel." 

Urates. — The  pathological  conditions  in  which  the  urates  are 
changed  are  much  the  same  as  those  in  which  alterations  in  uric 


638 


MEDICAL    DIAGNOSIS. 


acid  occur.  The  urates  consist  principally  of  urate  of  sodium,  of 
potassium,  and  of  ammonium.  The  deposits  formed  by  their 
precipitation  are  of  pink  color,  yet  sometimes  brown,  or  like 
brick-dust,  or  yellowish,  or  even  white.  From  pale  urine  of  low 
specific  gravity  a  white  sediment  is  apt  to  settle.  All  the  deposits 
are  dissolved  with  readiness  by  heat.  Acids  decompose  them  and 
separate  uric  acid.  They  are  all  more  soluble  in  warm  water  than 
in  cold,  and  the  neutral  salts  are  more  soluble  than  the  acid  ones. 
Under  the  microscope,  the  urates  are  seen  to  be  either  irregular, 
amorphous  particles,  needle-like  crystals,  dumb-bells,  or  round 
globules  of  various  sizes,  from  some  of  which  fine  needles  project. 
The  latter,  like  the  dumb-bells,  are  commonly  supposed  to  be  urate 
of  sodium;  the  globules  and  crystals,  urate  of  sodium  and  of  ammo- 
nium; the  granular,  amorphous  powder,  mixed  urates,  more 
especially  urate  of  sodium  and  of  potassium.  These  amorphous 
urates  may,  under  the  microscope,  be  mistaken  for  phosphate 
of  calcium.     The  differential  test  consists  in  their  behavior  with 

Fig.  42. 


Mixed  orates. 


acids ;  the  phosphate  is  dissolved  by  acetic  or  hydrochloric  acid ; 
the  urates  are  gradually  transformed  into  crystals  of  uric  acid. 
Then,  a  deposit  of  phosphate  of  calcium  is  often  more  cloudy 
than  the  urates,  and,  unlike  them  or  uric  acid,  not  soluble  in 
liquor  potassae.  From  carbonate  of  calcium,  which  also  occurs  in 
a  granular  form,  both  the  urates  and  the  phosphate  of  calcium 


THE  URINE  AND   DISEASES  OF  THE  URINARY  ORGANS.      639 

are  distinguished  by  the  effervescence  of  the  carbonic  acid  which 
happens  on  the  addition  of  a  strong  acid. 

Urine  containing  a  sediment  of  urates  is  generally  markedly 
acid,  or  soon  becomes  so,  either  from  an  absolute  increase  of  the 
uric  acid,  or  in  consequence  of  changes  in  some  of  the  constituents 
of  the  fluid — as  of  the  pigment — which  take  place  either  before  or 
shortly  after  emission.  Not  unfreqnently,  too,  it  is  scanty,  and 
the  urates  are  deposited  as  soon  as  the  urine  cools  to  the  tempera- 
ture of  the  atmosphere.  Their  precipitation  may  be,  and  indeed 
often  is,  owing  to  there  not  being  water  enough  to  hold  them  in 
solution.  We  may  judge  of  this  being  the  case,  by  ascertaining 
the  amount  of  urine  passed  in  twenty-four  hours.  If  the  quantity 
be  about  normal,  the  deposit  is  in  all  likelihood  due  to  an  excess 
of  urates.  In  cold  weather  these  deposits  occur  more  quickly  and 
more  extensively  than  in  warm. 

Sediments  of  urates  are  at  times  met  with  in  pale  urine,  and 
without  either  diminution  of  water  or  excess  of  acidity.  The 
urine  yields  but  a  faintly  acid,  or  a  neutral  or  alkaline  reaction, 
and  under  the  latter  circumstances  phosphate  of  calcium,  or  even 
triple  phosphates,  may  be  observed  to  accompany  the  urates.  The 
urates  present  are  always  the  acid  urates  of  ammonium. 

Phosphates. — The  phosphates  are  derived  in  part  from  the  food, 
in  part  from  the  disintegration,  or  rather  the  oxidation,  of  the 
disintegrated  albuminous  substances,  and  especially  of  the  nerve- 
structures.  They  occur  as  the  combination  of  phosphoric  acid 
with  calcium  and  magnesium,  forming  the  earthy  phosphates, 
which  exist  in  small  amounts,  about  1  gramme  in  twenty-four 
hours,  while  the  phosphate  of  sodium,  which  is  about  three  times 
as  abundant,  forms  the  greater  part  of  the  alkaline  phosphates. 

In  health  the  phosphates  are  kept  in  solution  by  the  acidity  of 
the  urine ;  but  as  soon  as  the  secretion  ceases  to  be  acid  they  are 
quickly  deposited.  Hence  the  appearance  of  phosphates  bespeaks 
a  neutral  or  alkaline  condition  of  the  urine,  with  the  exception  of 
the  calcium  phosphate  which  may  occur  in  acid  urine.  Often  the 
fluid,  as  we  have  already  seen,  becomes  alkaline  from  the  decom- 
position of  the  urea  into  carbonate  of  ammonium.  The  ammonia 
unites  with  the  phosphate,  forming  triple  salts,  ammonio-magne- 
sian  phosphates,  which  crystallize  commonly  in  transparent  prisms 
or  in  feathery-looking  bodies,  easily  distinguished  from  the  amor- 


640  MEDICAL    DIAGNOSIS. 

phous  powder  or  small  round  globules  of  phosphate  of  calcium. 
Yet  there  is,  as  Roberts  has  pointed  out,  a  crystalline  form  of  phos- 
phate of  calcium,  which  may  be  mistaken  for  one  of  the  stellar  forms 
of  crystallization  of  uric  acid,  from  which  it  may  be  distinguished 
by  being  invariably  colorless.  These  earthy  phosphates  are  all 
readily  soluble  in  acids,  even  in  weak  acids  like  acetic  acid,  and 
this  at  once  distinguishes  them,  even  under  the  microscope,  from 
oxalate  of  calcium,  which  some  forms  resemble.  In  many  speci- 
mens of  urine  they  are  precipitated  by  heat;  but  the  addition  of 
an  acid  soon  dissolves  them,  and  thus  prevents  the  turbidity  from 
being  mistaken  for  that  due  to  albumen. 

Fig.  43. 


Earthy  phosphates;  the  granules  are  chiefly  phosphate  of  calcium, 
the  rest  triple  phosphates. 

The  triple  phosphates  are  often  met  with  in  heavy  deposits 
mixed  with  pus;  in  the  alkaline  purulent  urine  resulting  from 
chronic  vesical  catarrh  they  are  very  common.  They  are  also 
seen  in  cases  of  retention  of  urine  in  the  bladder  due  to  its  tem- 
porary or  permanent  paralysis,  as  in  low  fevers,  in  hemiplegia, 
or  in  paraplegia.  They  are  found,  too,  in  many  affections  in  which 
the  vital  powers  have  been  seriously  lowered  and  the  acidity  of 
the  urine  diminished,  as  during  convalescence  from  acute  disease. 
Under  the  latter  circumstances,  and  in  fact  whenever  the  urine 
has  become  alkaline  from  the  presence  of  a  fixed  alkali,  the  phos- 
phatic  deposit  is  apt  to  show  a  large  excess  of  the  amorphous 
phosphates,  if,  indeed,  it  do  not  altogether  consist  of  then). 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.     641 

Urine  alkaline  from  fixed  alkali,  and  depositing  phosphates, 
is,  unless  this  condition  have  been  brought  about  temporarily  by 
fruit  or  other  food,  a  matter  of  serious  import.  "We  encounter  it 
in  persons  laboring  under  great  general  debility  and  indigestion 
associated  with  an  impaired  tone  of  the  nervous  system, — in  fact, 
in  those  of  whom  it  has  been  the  custom  to  speak  as  exhibiting  the 
"phosphatic  diathesis."  Such  a  morbid  state  is  not  uncommon 
in  men  depressed  by  mental  toil  or  anxiety. 

In  these  cases,  in  spite  of  the  distinct  sediment  of  the  phos- 
phates, it  is  very  doubtful  if  the  latter  are  really  increased  in 
quantity.  The  want  of  the  acidity  of  the  urine  permits  their  pre- 
cipitation, and  causes  them  to  become  readily  apparent;  just  as  it 
is  with  reference  to  deposits  of  urates,  where  the  sediment  may  be 
entirely  due  to  the  altered  reaction  of  the  urine,  and  not  to  excess- 
ive elimination.  On  the  other  hand,  .the  phosphates  may  be  ac- 
tually in  excess,  and  yet  this  excess  be  concealed  from  view.  This 
happens  especially  with  the  alkaline  phosphates,  the  proportions  of 
which  change  in  disease  much  more  than  do  the  earthy  phosphates, 
and  indicate  much  more  clearly  the  variations  of  the  phosphoric 
acid.  And,  paradoxical  as  it  may  appear,  the  acidity  of  the  urine 
may  be  so  much  augmented  by  the  increase  of  the  phosphoric  acid 
that  a  very  large  excess  of  alkaline  phosphates  may  be  present  in 
solution  in  a  highly  acid  urine. 

Now,  a  real,  not  merely  an  apparent,  increase  of  the  phosphates 
occurs,  according  to  Bence  Jones,  in  acute  inflammatory  diseases 
of  the  nervous  structure,  and  in  fractures  of  the  skull  when  an  in- 
flammatory action  takes  place  in  the  brain.  It  also  occurs  after 
mental  strain.  Beale,  however,  does  not  regard  the  excess  of 
phosphates  as  being  a  sign  of  wear  and  tear  of  nervous  tissue. 
"We  find  the  phosphates  also  augmented  by  the  abundant  use  of 
animal  food,  by  very  active  exercise,  and  in  acute  rheumatism. 
The  earthy  phosphates  are  markedly  increased  in  rickets  and  in 
extensive  bone  disease;  the  phosphoric  acid,  as  well  as  the  sul- 
phuric acid,  the  urea,  and  the  chloride  of  sodium,  is  excreted  in 
less  amount  than  in  health  during  the  course  of  a  maniacal 
paroxysm,  in  epilepsy,  and  in  melancholia.* 

To  determine  the  proportion  of  the  earthy  phosphates,  a  few 

*  Adam  Addison,  Brit,  and  For.  Med.-Chir.  Kev.,  April,  1865. 

41 


642  MEDICAL    DIAGNOSIS. 

drops  of  ammonia  are  added  to  the  urine;  soon  a  whitish  precipi- 
tate is  produced,  which  is  not  dispersed  by  heat.  From  the  quan- 
tity of  the  deposit,  after  settling,  we  may  form  a  rough  estimate 
of  that  of  the  earthy  phosphates.  In  an  ordinary-sized  test-tube  a 
deposit  1  c.  high  represents  a  normal  amount.  But  if  the  amount 
is  to  be  accurately  ascertained,  we  must  employ  a  graduated  glass, 
separate  the  precipitated  phosphates  by  filtration,  ignite  them  in  a 
platinum  capsule,  and  weigh  the  ashes.  The  alkaline  phosphates 
are  not  thrown  down  by  alkalies,  and,  unlike  the  earthy  phosphates, 
are  very  soluble  in  water.  They  are  procured  by  taking  the  fluid 
from  which  the  earthy  phosphates  have  been  carefully  removed  by 
filtration,  and  adding  to  it  a  saturated  solution  of  sulphate  of  mag- 
nesium. Or  we  add  to  the  urine  about  one-third  as  much  of  the 
magnesium  mixture,  and  if  the  precipitate  be  copious,  giving  the 
fluid  the  appearance  of  cream,  then  the  alkaline  phosphates  are  in 
excess;  if  there  be  merely  a  milky  turbidity,  they  are  normal. 

From  the  deposit  obtained  in  testing  for  the  phosphates,  some 
idea  may  also  be  formed  of  the  quantity  of  phosphoric  acid  in  the 
urine.  The  average  quantity  passed  by  an  adult  male  in  twenty- 
four  hours  is,  according  to  Vogel,  about  3.5  grammes,  or  nearly 
53  grains.  For  the  volumetric  processes  by  which  the  amount  of 
the  acid  may  be  determined,  I  refer  to  special  treatises  on  the 
chemistry  of  the  urine, — to  such  works  as  those  of  Neubauer, 
Beale,  and  Thudichum. 

Chlorides. — The  chlorides  in  the  urine  are  derived  from  the 
food  ;  they  correspond  closely  with  the  amount  of  salt  ingested. 
In  consequence,  the  chloride  of  sodium — the  main  chloride  in  the 
urine,  for  it  contains  a  mere  trace  of  chloride  of  potassium  and 
chloride  of  calcium — is,  even  in  health,  liable  to  great  fluctuations ; 
the  mean  in  twenty-four  hours  is  estimated  by  Vogel  and  Parkes 
at  11.5  grammes,  or  about  177  grains.  Bischoff  states  the  average 
at  14.73  grammes.  Large  quantities  of  chlorides  are  excreted  after 
active  bodily  or  mental  exercise,  smaller  quantities  when  the  body  is 
at  rest,  as  at  night.  In  disease,  very  various  amounts  are  elimi- 
nated with  the  urine.  In  cases  of  chronic  indigestion  and  of  dropsy 
the  chlorides  are  diminished.  In  typhus  fever  and  in  acute  inflam- 
matory affections  they  sink  to  a  low  level,  and  rise  again  in  conva- 
lescence: an  increase  after  a  diminution  is  thus  always  a  favorable 
sign.     We  may  study  these  changes  in  pleurisy  and  pericarditis, 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.     643 

but  especially  in  pneumonia.  At  the  period  of  hepatization  the 
chlorides  are  absent  from  the  urine,  and  appear  in  increased  quan- 
tity in  the  sputum ;  during  resolution  they  reappear  in  the  urine; 
between  these  stages  there  is,  probably,  a  determination  of  the  salt 
to  the  inflamed  organ. 

Chloride  of  sodium  is  detected  with  ease.  The  urine  is  acidu- 
lated with  nitric  acid,  and  a  solution  of  nitrate  of  silver  is  added  ; 
a  dense  white  precipitate  of  chloride  of  silver  quickly  takes  place, 
insoluble  in  nitric  acid,  but  soluble  in  ammonia.  The  amount  of 
the  chloride  is  approximately  estimated  by  comparison  with  healthy 
urine,  or  by  employing  the  method  of  Hofmann  and  Ultzmann. 
According  to  this  method,  if  in  using  a  solution  of  nitrate  of  silver 
of  definite  strength,  1  to  8,  we  find  curdy  masses  of  chloride  of 
silver  falling  to  the  bottom,  which  on  shaking  the  glass  do  not 
separate,  we  judge  the  chlorides  to  be  in  normal  amount.  If  the 
precipitate  of  chloride  of  silver  be  small,  -j^th  per  cent,  or  less,  a 
simple  milky  turbidity  arises  and  no  curdy  mass  deposits ;  whereas 
if  the  chlorides  be  entirely  wanting  there  is  neither  milky  cloud 
nor  turbidity.  If  the  urine  contain  much  albumen,  it  must  be 
filtered  oif  before  the  test  is  applied. 

Sulphates. — The  sulphates  are  found  in  the  urine  in  large 
quantities.  They  consist  of  sulphate  of  potassium  and  sulphate  of 
sodium ;  the  former  in  excess.  Like  the  alkaline  phosphates,  they 
are  dissolved  in  the  urine,  and  must  be  precipitated.  To  effect 
this,  a  few  drops  of  nitric  acid  are  added  to  urine,  and  subsequently 
from  fifteen  to  twenty  drops  of  a  saturated  solution  of  chloride  of 
barium,  when  a  white  precipitate  insoluble  in  acids  occurs.  If 
there  be  merely  an  opaque  milky  cloudiness,  the  sulphates  are  in 
normal  quantity. 

The  sulphates  are  obtained  in  part  from  the  food,  in  part  from 
the  oxidation  of  the  sulphur  entering  into  the  constitution  of  the 
albuminous  substances  of  the  body  and  the  subsequent  union  with 
a  base  of  the  sulphuric  acid  which  is  formed.  They  are  enhanced 
by  an  exclusively  animal  diet,  and  after  violent  exercise,  and  in 
acute  febrile  processes  with  large  excretion  of  urea ;  in  fact,  their 
increase  is  apt  to  go  hand  in  hand  with  that  of  urea.  An  excep- 
tion to  this  is  noticed  by  Parkes*  in  rheumatic  fever.     Here  the 

*  British  and  Foreign  Medico-Chirurgical  Keview,  vol.  xiii. 


644  MEDICAL    DIAGNOSIS. 

sulphuric  acid  in  the  urine  is  greatly  augmented,  but  the  urea  not 
correspondingly  so.  The  administration  of  potassium  raises  in  a 
striking  degree  the  proportion  of  the  sulphates.  The  sulphates 
show  decrease  during  an  exclusively  vegetable  diet  and  in  urine 
of  low  specific  gravity. 

The  average  daily  quantity  of  sulphuric  acid  passed  in  the  uriue 
is  about  2  grammes.  Vogel  gives  an  easy  method  of  determining 
approximately  whether  it  is  increased  or  diminished.  After  ascer- 
taining the  whole  amount  of  urine  in  twenty-four  hours, — say  it 
is  2000  cc,  and  then  each  100  cc.  would  contain  0.10  gramme  of 
sulphuric  acid, — 100  cc.  are  rendered  acid,  and  as  much  of  a  test 
solution  of  chloride  of  barium*  is  added  as  corresponds  with  0.05 
gramme  of  the  acid.  The  mixture  is  nowT  filtered,  and  if  the 
filtered  liquid  be  not  made  turbid  by  the  chloride  of  barium,  we 
may  infer  that  the  patient  has  secreted  less  than  1  gramme  of  sul- 
phuric acid  in  the  twenty-four  hours.  If  the  liquid,  however,  be 
rendered  turbid  by  chloride  of  barium,  a  further  quantity  of  this 
agent,  corresponding  with  0.5  gramme  of  sulphuric  acid,  is  added  ; 
and  if  the  filtrate  be  still  rendered  turbid,  it  is  evident  that  the 
quantity  of  sulphuric  acid  is  greater  than  normal. 

Kreatine  and  Kreatinine. — These  substances  found  in  the  urine 
are  purely  excrementitious,  and  are  derived  from  a  disintegration 
of  the  muscular  tissue.  Kreatinine  is  the  product  of  the  change 
of  kreatine.  Indeed,  it  is  now  generally  believed  that  the  former 
alone  exists  in  urine.     About  1  gramme  is  excreted  daily. 

But  few  observations  have  as  yet  been  made  on  the  increase  of 
kreatine,  or  on  its  significance  in  showing  the  activity  of  nutrition 
in  the  muscles  in  health  or  in  disease.  Active  muscular  exercise 
augments  the  quantity ;  and  the  same  effect  is  probably  produced 
by  all  spasmodic  affections,  and,  as  Munk  has  shown,  at  the  height 
of  acute  disease,  while  kreatine  is  diminished  during  convales- 
cence, and  in  advanced  degeneration  of  the  kidneys. 

Both  kreatine  and  kreatinine  are  generally  included,  in  analyses, 
under  the  head  of  extractives.  Kreatine  is  separated  by  a  con- 
centrated solution  of  chloride  of  zinc.     But  for  the  chemical  par- 


*  Made  generally  by  dissolving  30.5  grammes  of  crystallized  chloride  of 
barium,  powdered  and  air-dried,  and  diluting  the  solution  up  to  1  litre ;  1  cc. 
of  it  then  equals  10  milligrammes  of  anhydrous  sulphuric  acid. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.     645 

ticulars  I  must  refer  to  special  works  on  the  chemistry  of  the 
urine,  especially  to  Neubauer  and  Vogel.  Under  the  microscope, 
the  crystals  of  kreatine  are  colorless  and  beautifully  transparent. 
Their  appearance,  as  well  as  that  of  kreatinine,  is  faithfully  repre- 
sented in  Robin  and  Verdeil's  plates.* 

Presence  of  Abnormal  Substances  in  the  Urine. — Here 
may  be  mentioned  the  ingredients  which  are  observed  in  the  urine 
in  disease  only,  as  bile  and  blood ;  and  along  with  them  I  shall 
notice  those  constituents  the  occurrence  of  which  in  healthy  urine 
is  occasional,  but  of  which  it  is  certain  that  their  presence  in  any 
marked  degree  is  abnormal. 

Oxalate  of  Lime, — There  can  be  no  doubt  that  the  salt  may  be 
detected  in  the  urine  of  persons  who  enjoy  good  health;  but  equally 
there  can  be  no  doubt  that  the  crystals  are  not  found  in  large 
numbers  except  in  a  morbid  condition.  Some  pass  habitually  a 
considerable  quantity  of  oxalic  acid  in  the  form  of  oxalate  of  lime. 
They  are  generally  persons  weighed  down  by  care  and  anxiety,  or 
who  overtask  their  brains  by  incessant  application  to  study,  or 
weaken  their  nervous  power  by  excessive  sexual  indulgence  or  by 
masturbation.  Sometimes  they  are  troubled  with  frequent  semi- 
nal emissions  and  irritation  of  the  bladder,  or  they  are  dyspeptic, 
and  suffer  from  uneasiness  after  meals ;  but  the  appetite  may  be 
good  and  the  digestion  unimpaired.  They  are  always  languid, 
and  either  very  irritable  or  very  dejected.  Frequently  they  com- 
plain of  loss  of  memory,  and  of  a  sensation  of  weight  or  of  a  dull 
pain  across  the  loins.  They  are  liable  to  boils  and  carbuncles, 
grow  thin,  and  evidently  are  generally  out  of  health.  The  urine  is 
of  high  specific  gravity,  shows  an  increase  of  urea,  and  ordinarily  a 
cloudy  deposit  consisting  of  mucus  and  the  crystallized  oxalates. 

This  is  the  disorder  called  by  Golding  Bird  oxaluria,  and  which 
is  generally  combined  with  tissue-changes  and  increased  excretion 
of  urea.  Its  existence  as  a  separate  affection  has  been  denied ; 
but  that  the  formation  of  oxalate  of  lime  in  any  considerable 
quantity  is  associated  with  the  symptoms  described,  can  be  satis- 
factorily ascertained  by  any  one  who  will  take  the  trouble  to  ex- 
amine the  urine  with  care,  in  cases  like  those  referred  to.  The 
origin  of  the  oxalic  acid,  however,  is  not  certain.     Golding  Bird 

*  Traite  de  Chiniie  anatomique,  Paris,  1853. 


646 


MEDICAL    DIAGNOSIS. 


attributed  it  to  a  secondary  or  destructive  assimilation  of  tissue. 
The  evidence  is  certainly  in  favor  of  its  being  formed  in  the  system, 
for  it  has  been  found  in  the  blood.  Still,  it  is  not  improbable  that 
it  may  at  times  be  the  product  of  a  species  of  fermentation  oc- 
curring in  the  urinary  passages,  and  therefore  after  the  urine  is 
secreted  ;  and  it  is  known  that  oxidation  of  uric  acid  and  the  urates, 
and  the  imperfect  oxidation  of  sugar,  of  starch,  and  of  the  salts  of 
the  vegetable  acids,  may  occasion  it.  Probably  in  the  first  class  of 
cases  alone  are  the  constitutional  symptoms  described  present.  In 
the  others  we  may  at  times  detect  evidence  of  the  irritation  of  a 
calculus,  or  of  disease  of  the  bladder  or  the  kidneys.* 

Fig.  44. 


Crystals  of  oxalate  of  lime. 

Oxalate  of  lime  may  be  detected  in  the  urine  when  articles 
which  contain  it,  such  as  sorrel  and  the  rhubarb  plant,  have  been 
eaten,  or  after  the  free  use  of  carbonated  drinks.  It  may  be  also 
found  in  the  urine  of  those  recovering  from  severe  acute  maladies, 
and  is  encountered,  but  only  in  very  small  quantities,  in  the  urine 


*  Shunck*  has  established  the  presence  in  normal  urine  of  oxaluric  acid, 
which  he  thinks  presents  a  satisfactory  solution  of  the  formation  of  oxalate  of 
lime.  The  conversion  of  oxaluric  acid  into  oxalic  acid  may  take  place  after 
the  urine  is  voided,  or  begin  in  the  bladder,  or  even  in  more  remote  parts  of 
the  urinary  apparatus,  and  thus  lead  to  the  formation  of  calculi  of  oxalate  of 
lime.     The  oxaluric  acid  is  derived  from  the  oxidation  of  uric  acid*. 


*  Proceedings  of  the  Koyal  Society,  vol.  xvi.  p.  140;  On  Oxalurate  of  Ammonia  as  a  Constituent 
of  the  Human  Urine. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.       647 

of  healthy  persons.  But  in  neither  instance  is  it  at  all  permanent, 
nor  can  the  presence  of  a  few  crystals  be  looked  upon  as  of  the 
least  importance. 

The  microscope  is  incomparably  the  readiest  means  of  detecting 
the  salt.  This  appears  in  the  urine  in  well-defined  octahedra  of 
most  varying  size,  and  in  dumb-bell  bodies.  The  former  are 
much  the  more  common  and  characteristic,  for  the  dumb-bells  are 
not  frequent,  nor  is  this  formation  peculiar  to  oxalate  of  lime. 
Occasionally,  long  or  pointed  octahedra  or  prismatic  crystals  are 
observed.  The  crystals  of  oxalate  of  lime  are  unaffected  by 
acetic  acid. 

The  oxalates  are  often  mixed  with  deposits  of  urates  or  uric 
acid.  Sometimes — Beneke  says  constantly — the  earthy  phos- 
phates coexist  in  large  amount  with  the  oxalates.  Occasionally 
the  irritation  from  the  passage  of  the  crystals  gives  rise  to  tube- 
casts.  A  case  came  under  my  observation  years  since  in  which  a 
patient  suffering  from  a  protracted  attack  of  oxaluria  voided  for 
weeks,  along  with  the  oxalates,  hyaline,  exudative,  or  small  waxy 
casts.  Neither  heat  nor  nitric  acid  detected  albumen.  Under 
treatment,  the  crystals  disappeared  from  the  urine,  and  with  them 
the  casts.  The  gentleman  recovered  perfectly.  He  has  not  to 
this  day  had  the  slightest  signs  of  degeneration  of  the  kidneys. 

Leucine  and  Tyrosine. — Both  these  substances  are  the  result  of 
the  decomposition  of  highly  nitrogenous  animal  matter,  are  very 
similar,  and  are  usually  associated.  They  replace  urea,  and  have 
been  found  in  the  urine  only  in  disease,  as  in  yellow  atrophy 
of  the  liver,  in  typhoid  fever,  in  smallpox,  and  in  phosphorus- 
poisoning.  They  are  either  spontaneously  deposited,  or  form  a 
deposit  if  a  small  quantity  of  urine  be  evaporated.  Tyrosine  is 
readily  detected  by  the  microscope.  It  crystallizes  in  long,  very 
fine,  shining  needles,  which  may  congregate  in  globular  bodies. 

Hofmann  has  proposed  the  following  delicate  chemical  test  for 
tyrosine.  A  solution  of  mercuric  nitrate,  nearly  neutral,  is  to  be 
treated  with  the  solution  suspected  to  contain  tyrosine :  if  it  be 
present,  a  reddish  precipitate  is  produced,  and  the  supernatant  fluid 
is  of  a  very  dark  rose-color.  Leucine  crystallizes  in  granular 
masses,  consisting  of  roundish  globules,  sometimes  of  concentric 
form,  and  for  the  most  part  of  yellowish  color,  and  resembling  oil- 
drops,  but,  unlike  oil,  is  not  dissolved  by  ether.     The  chemical 


648  MEDICAL    DIAGNOSIS. 

test  for  leucine  is  to  place  the  suspected  deposit  on  platinum  foil 
and  then  to  evaporate  it  with  nitric  acid.  The  residue  is  moist- 
ened with  caustic  soda,  and  this  mixture  carefully  heated  over  a 
spirit-lamp.  It  is  gradually  condensed  into  oily-looking  drops;  a 
property  which  Scherer  has  pointed  out  as  characteristic  of  leucine. 

Bile. — The  occurrence  of  bile  in  the  urine  imparts  to  it  a  very 
dark  color.  Its  presence  is  a  proof  that  the  bile  passes  into  the 
blood,  and  that  the  kidneys  are  performing  a  function  forced  on 
them  by  the  deranged  action  of  the  liver,  or  by  an  impediment  in 
the  biliary  passages.  All  the  constituents  of  the  bile  may  appear 
in  the  urine,  or  only  the  pigment,  without  the  acids  or  their  salts. 
The  pigment  is  sometimes  found  transiently,  and  in  small  quan- 
tities, without  yellowness  of  the  skin  :  its  more  permanent  and 
marked  occurrence  is,  however,  always  attended  with  jaundice. 
It  may  be  discerned  both  before  the  discoloration  of  the  skin  is 
noticeable,  and  after  it  has  lost  its  yellow  hue.  The  biliary  acids 
are  not  of  necessity  present  in  the  urine  of  icterus. 

The  detection  of  the  coloring-matter  of  bile  is  effected  by  pour- 
ing a  small  quantity  of  urine  on  a  white  plate;  a  drop  of  nitric 
acid,  or,  better  still,  of  the  yellow  fuming  nitric  acid  of  commerce, 
is  then  permitted  to  fall  on  the  thin  layer  of  fluid.  Soon  a  play  of 
color  takes  place,  beginning  with  green  and  blue,  passing  to  violet 
and  red,  and  often  finally  to  yellow  or  brown  ;  the  green  is  the 
predominant  and  the  most  characteristic  of  the  colors.  Accord- 
ing to  Frerichs,*  this  reaction  may  fail  in  cases  where  the  other 
symptoms  of  jaundice  are  undoubted,  owing  to  the  bile-pigment 
having  already  passed  through  stages  of  transformation.  When 
this  is  the  case,  the  urine  is  at  one  time  of  a  brown  or  brownish- 
red  color,  and  becomes  red  on  the  addition  of  nitric  acid  ;  at 
another  time  it  is  of  a  deep  red,  which  is  converted  by  nitric  acid 
into  a  dark  bluish-red.  Murchison  has  made  a  similar  observa- 
tionf  in  rare  cases  where  jaundice  has  resulted  from  a  blood-poison, 
and  he  has  frequently  found  the  urine  to  present  these  characters 
where  there  has  been  no  jaundice,  yet  obvious  derangement  of  the 
liver. 

Heller's  test  is  also  very  easily  performed.     In  a  small  beaker 


*  Diseases  of  the  Liver,  Sydenham  Soc.  Transl.,  vol.  i.  p.  100. 
f  Clinical  Lectures  on  Diseases  of  the  Liver. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.     649 

glass  containing  about  6  cc.  (1.62  fluidrachms)  of  pure  hydro- 
chloric acid  mix  enough  urine  to  discolor  this,  then  allow  nitric 
acid  to  trickle  along  the  sides  and  form  a  layer  underneath.  A 
beautiful  play  of  colors  takes  place  at  the  point  of  contact,  and,  on 
stirring  up  the  mixture  with  a  glass  rod,  throughout  it. 

Basham*  speaks  of  the  following  test  for  bile-pigment  as  being 
very  delicate.  The  urine  is  shaken  up  with  a  small  quantity  of 
chloroform,  which  dissolves  out  the  bile  coloring-matter  and  re- 
tains it  in  solution.  If  this  solution  be  decanted  and  evaporated 
carefully,  the  pigment  which  is  left  gives,  on  the  addition  of  a 
drop  of  nitric  acid,  a  beautiful  ruby-red  color,  after  displaying  the 
characteristic  play  of  colors.  This  test  is  equally  available  for 
detecting  bile-pigment  in  other  fluids. 

Carter  tells  usf  that  urine  containing  an  excess  of  indican  pre- 
sents the  same  succession  of  colors,  when  treated  with  nitric  acid, 
as  urine  holding  bile-pigment  in  solution.  To  avoid  this  fallacy 
in  a  doubtful  case,  the  urine  should  be  treated  with  sulphuric  acid, 
as  described  while  discussing  indican.  If  the  mixture  become 
black  and  opaque,  depositing  a  deep  blue  or  purple  precipitate  on 
being  diluted  with  water,  the  play  of  colors  may  be  attributed  to 
the  excess  of  indican. 

If  the  urine  contain  only  altered  biliary  coloring-matters  (bili- 
fusin),  they  may,  according  to  Hofmann  and  Ultzmann,  be  rec- 
ognized as  follows.  A  piece  of  clean  white  linen  is  dipped  into 
the  urine  and  then  allowed  to  dry  ;  it  is  discolored  brown.  Fur- 
ther confirmation  is  found  in  a  very  dark  reaction  for  urophaein 
(by  adding  about  double  the  quantity  of  urine  to  strong  sulphuric 
acid),  the  urine  appearing  not  garnet  red,  but  only  black.  A  sim- 
ilar reaction  is  produced  only  by  the  presence  of  sugar  and  of 
blood-coloring  matter,  both  of  which  can  be  excluded  by  the  ap- 
propriate tests. 

The  biliary  acids  are  sought  for  by  Pettenkofer's  test.  It  con- 
sists in  tincturing,  with  a  few  drops  of  a  solution  of  sugar,  a  small 
portion  of  urine  contained  in  a  test-tube  or  in  a  china  dish,  placed 
in  cold  water.  To  this  mixture  an  excess  of  concentrated  sulphu- 
ric acid  is  added,  drop  by  drop.  The  fluid  assumes  a  yellowish- 
red  color,  which,  if  bile  be  present,  passes  into  a  crimson  or  violet. 

*  Eenal  Diseases.  j  Edinb.  Med.  Jour.,  Aug.  1859,  p.  125. 


650  MEDICAL    DIAGNOSIS. 

The  test  is  not  applicable  to  albuminous  urine,  unless  the  albu- 
men be  first  coagulated  and  separated.  And  it  is  inconclusive; 
for  urine  containing  an  excess  of  indican  may  display,  when  thus 
treated,  a  reaction  exactly  similar  to  that  caused  by  the  bile  acids. 
Moreover,  Neubauer  and  Vogel  state  that  oleic  acid  and  albu- 
men give  analogous  reactions.* 

Sugar. — This  substance  is  not  a  normal  ingredient  of  urine,  or 
exists  only  in  traces  too  minute  to  be  detected  by  the  ordinary 
tests.  When  met  with  in  healthy  urine  it  is  probably  due  to  the 
decomposition  of  the  indican.  Sugar  may  be  found  occasionally 
in  the  urine  of  those  who  live  exclusively  on  a  starchy  diet,  or 
who  take  large  quantities  of  sugar;  but  the  proportion  even  then 
is  very  small.  The  urine  secreted  while  under  the  influence  of 
turpentine,  ether,  chloroform,  chloral,  amyl  nitrite,  is  found  to 
respond  to  the  copper  tests  for  sugar.  And  Bordierf  has  grouped 
together  many  observations  which  led  him  to  conclude  that  dia- 
betes may  be  considered  as  an  almost  normal  occurrence  in  the 
stage  of  recovery  from  acute  diseases.  Measles,  pneumonia,  ery- 
sipelas, all  inflammatory  fevers,  are  liable  to  its  production  during 
convalescence.  It  may  be  detected  in  certain  lesions  of  the  brain 
and  spinal  cord.  At  Guy's  Hospital  the  urine  of  a  large  num- 
ber of  patients,  laboring  under  various  complaints,  was  found  in 
several  instances,  particularly  in  cases  of  phthisis,  to  give  a  more 
or  less  marked  reaction  of  sugar.J  But  a  large  and  persistent 
amount  occurs  only  in  diabetes. 

Urine  holding  sugar  in  solution  is  light-colored,  of  high  specific 
gravity,  and  of  peculiar  smell.  It  rarely  deposits  sediments,  and 
the  excess  of  water  in  it  is  enormous. 

To  detect  the  presence  of  sugar,  several  tests  have  been  proposed, 
nearly  all  of  which  are  easy  of  application,  and  whichever  be  em- 
ployed, when  albumen  is  present  in  any  amount,  this  should  be 
first  separated  by  boiling  and  filtering. 

Moore's  test  is  the  simplest.  It  consists  in  boiling  the  suspected 
fluid  with  about  an  equal  quantity  of  hydrate  of  potassium  (liquor 

*  On  the  general  value  of  the  test  consult  Murchison  on  the  Liver,  Neu- 
bauer and  Yogel's  Analysis  of  the  Urine,  and  Tyson,  Philadelphia  Medical 
Times,  July,  1873. 

f  Archives  Generates  de  Medecine,  18G8. 

%  Researches  on  Diabetes,  by  F.  W.  Pavy. 


THE  URINE  AND  DISEASES   OF  THE  URINARY  ORGANS.     651 

potassse).  The  mixture,  if  it  contain  sugar,  becomes  of  a  deep- 
brown  color,  which  grows  deeper  the  longer  the  boiling  is  con- 
tinued ;  but  if,  as  Heller  uses  the  test,  a  few  drops  of  nitric  acid 
be  now  added,  the  dark  color  speedily  disappears  and  a  smell  of 
burned  molasses  is  given  off.  This  method,  although  good,  is 
not  to  be  depended  upon  when  the  urine  contains  only  traces  of 
sugar ;  nor  ought  the  change  of  hue,  when  slight,  to  be  accepted 
as  conclusive,  for  other  things  besides  sugar  affect  it.  Indeed,  it  is 
always  better  to  corroborate  by  other  tests  the  evidence  obtained. 

The  change  of  color,  if  it  take  place  when  the  liquor  potassse  is 
first  added  and  prior  to  heating,  is  generally  due  to  decomposed 
biliary  coloring-matter.  From  the  intensity  of  the  color  pro- 
duced in  saccharine  urine  by  the  hydrate  of  potassium  test,  Neu- 
bauer  has  proposed  by  a  color  scale  to  judge  approximately  of  the 
amount  of  sugar. 

Trommer's  test  is  more  delicate.  A  few  drops  of  a  solution 
of  sulphate  of  copper  are  dropped  into  the  test-tube  holding 
the  urine.  Liquor  potassse  is  now  added  in  excess.  If  the 
fluid  be  saccharine,  the  faint  greenish  tint  is  changed  to  a  deep 
blue,  the  precipitate  which  is  formed  when  the  alkali  is  first  added 
being  soon  redissolved.  On  heating  the  blue  mixture  it  becomes 
brownish,  then  yellow,  and  finally  a  reddish-brown  mass  of  sub- 
oxide of  copper  is  thrown  down,  very  different  from  the  flocculent 
or  greenish  sediment  noticed  when  no  sugar  exists.  A  very  small 
quantity  of  sugar  can  be  detected  by  this  process :  but,  good  as  the 
test  is,  it  has  its  drawbacks;  for  sugar  is  not  the  only  substance 
which  possesses  the  power  of  reducing  the  salts  of  copper.  Chlo- 
roform, kreatinine,  and  to  some  extent  uric  acid  and  the  urates, 
share  with  it  this  property.  Furthermore,  Beale  has  shown  that 
the  presence  of  ammoniacal  salts  will  prevent  the  precipitation  of 
the  suboxide  in  urine  containing  but  little  sugar. 

'Fehling's  test  is  a  convenient  modification  of  the  copper  test  for 
ready  use,  and  may  be  also  employed  for  the  quantitative  deter- 
mination of  sugar.  This  is  the  direction  for  its  preparation  :  dis- 
solve 69  grains  of  crystallized  sulphate  of  copper  in  five  times 
its  weight  of  distilled  water,  add  a  concentrated  solution  of  268 
grains  of  tartrate  of  potassium,  and  then  a  solution  of  80  grains 
of  hydrate  of  sodium  in  1  ounce  of  distilled  water;  enough  water 
is  now  poured  into  the  vessel  to  make  1000  grains  of  the  mix- 


652  MEDICAL    DIAGNOSIS. 

hire, — each  100  grains  of  which  will  be  equivalent  to  1  of  grape 
sugar.* 

The  copper  solution  employed  by  Neubauer  is  34.639  grammes 
of  pure  crystallized  sulphate  of  copper  dissolved  in  about  200 
grammes  of  water.  173  grammes  of  crystallized,  chemically-pure 
potassio-sodic  tartrate  are  dissolved  in  500  or  600  grammes  of 
sodic  hydrate  of  specific  gravity  1.12,  and  the  sulphate  of  copper 
solution  is  gradually  added  to  this  alkaline  solution.  The  clear 
mixed  fluid  is  then  diluted  to  one  litre.  10  cc.  of  this  copper 
solution  are  exactly  reduced  by  0.05  of  grape  sugar. 

Pavyf  uses  a  liquid  containing  caustic  potassa;  of  which  100 
minims  reduce  exactly  half  a  grain  of  grape  sugar.  It  consists 
of  sulphate  of  copper,  320  grains;  tartrate  of  potassium  (neutral), 
640  grains;  caustic  potassa  (fusa),  1280  grains;  distilled  water, 
20  fluidounces.  This  test  will  be  found  more  delicate,  as  well  as 
more  striking,  by  boiling  the  test  liquid  first  and  then  adding 
the  urine  drop  by  drop.  If  sugar  be  present,  it  will  produce  a 
reddish  or  yellowish  opaque  precipitate,  the  difference  in  color 
depending  merely  upon  the  deficiency  or  the  excess  of  the  test 
liquid.  If  no  such  reaction  ensue,  urine  should  be  added  until 
a  bulk  nearly  equal  to  that  of  the  test  liquid  has  been  poured 
in,  and  the  whole  should  then  be  boiled  again  ;  the  characteristic 
change  not  yet  occurring,  the  urine  should  be  set  aside  to  cool. 
If  it  contain  less  than  half  a  grain  per  cent,  of  sugar,  the  pre- 
cipitation will  occur  as  the  liquid  cools.  The  mixture  first  loses 
its  transparency,  and  passes  from  a  clear  olive-green  to  a  light- 
greenish  opacity,  looking,  as  Roberts  describes  it,  as  if  some 
drops  of  milk  had  fallen  into  the  tube.  This  green,  milky  ap- 
pearance is  characteristic  of  a  small  amount  of  sugar.  If  no 
milkiness  be  produced,  the  urine  can  be  confidently  pronounced 
free  from  sugar. 

For  the  quantitative  analysis  of  sugar  contained  in  diabetic 
urine,  the  test  liquid  is  used  as  follows.  In  an  ordinary  case  of 
diabetes,  the  urine  is  diluted  with  four  times  its  bulk  of  water, 
mixed  in  a  narrow  graduated  glass  divided  into  100  measures. 
One  hundred  minims  of  the  blue  test  fluid  are  now  placed  in  a 

*  Lehmann's  Physiological  Chemistry,  vol.  i.  p.  255,  Amor.  ed. 
f  Researches  on  Diabetes,  2d  ed. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.       653 

small  porcelain  capsule  with  a  fragment  of  solid  caustic  potassa 
about  double  the  size  of  a  pea,  if  Pavy's  solution  be  employed. 
The  contents  of  the  capsule  are  made  to  boil  over  a  spirit-lamp, 
and  the  diluted  urine  is  dropped  into  it  slowly  from  a  graduated 
glass,  until  the  blue  color  is  entirely  removed.  The  amount  of 
diluted  urine  employed  is  read  off  from  the  graduated  scale  of  the 
tube.  Let  us  say  it  takes  30  minims  to  decolorize  the  100  minims 
in  the  capsule :  that  would  be  ^  grain  of  sugar  in  each  30  minims, 
or  8  grains  to  the  ounce  of  diluted  urine ;  and,  as  the  urine  has 
been  diluted  to  the  extent  of  one-fifth,  the  8  grains  must  be 
multiplied  by  5  to  get  the  amount  of  sugar  really  present  in  an 
ounce  of  the  urine. 

The  oxides  of  other  metals  besides  copper  are  reducible  by  grape 
sugar.  In  accordance  with  this  well-ascertained  fact,  a  test  by 
bismuth  has  been  proposed  by  Bottger.  A  small  amount  of  sub- 
nitrate  of  bismuth  is  boiled  with  urine,  to  which  first  about  one- 
third  of  the  quantity  of  liquor  potassse  has  been  added.  If  sugar 
be  present,  a  gray  or  black  sediment  announces  the  reduction  of  the 
oxide  to  a  black  suboxide.  I  use  this  test  frequently,  and  find  it 
very  satisfactory.  It  is  only  not  to  be  depended  on  where  albumen 
is  present,  or  a  sulphur  compound.  Under  these  circumstances 
Briicke  recommends  the  acidulation  with  hydrochloric  acid  and 
the  use  of  Frohu's  reagent,  containing  iodide  of  bismuth  and 
potassium.* 

The  bismuth  test  enables  us  to  distinguish  alkapton,  a  substance 
which  Baedecker  has  found  in  the  urine  treated  with  hydrate  of 
potassium ;  the  fluid  gradually  colors  brown  from  above  down- 
ward. The  bismuth  salt  is  not  reduced  by  this  body  ;  the  copper 
salt  is. 

The  bismuth  test  has  been  recently  modified,  to  render  its  re- 
sults still  more  trustworthy,  by  Dudley.f  The  subnitrate  of  bis- 
muth is  first  dissolved  in  the  least  possible  quantity  of  pure  nitric 
acid,  and  an  equal  amount  of  acetic  acid  is  added. 

The  copper  solutions  are  liable,  after  some  time,  especially  if 
exposed  to  the  light,  to  allow  a  slight  reduction  to  occur  on  boil- 
ing without  any  sugar  being  present.     The  test  liquid  itself,  if  not 


*  Hofmann  and  Ultzmann,  Amer.  Trans].,  New  York,  1879,  p.  93. 
f  American  Chemical  Journal,  vol.  ii.  No.  1. 


654  MEDICAL    DIAGNOSIS. 

fresh,  should  be  tested  by  boiling,  and  if  any  change  occur,  a 
fragment  of  sodic  hydrate  if  Fehling's,  or  of  potassic  hydrate  if 
Pavy's  solution  be  used,  will  render  it  again  fit  for  use.  Knapp* 
has  proposed  a  cyanide  of  mercury  solution,  which  is  much  more 
durable. 

Recently  various  pastes  and  solid  pellets,  based  on  the  copper 
test,  have  been  suggested  for  ready  use,  as  by  Pavy f  and  Piffard  jj 
and  Neff§  has  introduced  some  cupric  pellets  which  may  be  easily 
employed  for  quantitative  analysis,  each  pellet  representing  accu- 
rately five  milligrammes  of  grape  sugar.  The  pellet  is  dissolved 
in  4  cc.  of  distilled  water  in  a  test-tube;  1  cc.  of  urine  is  diluted 
to  10  with  distilled  water;  the  urine  thus  diluted  is  dropped 
from  a  burette  into  the  boiling  test  solution  until  the  color  is 
entirely  destroyed,  then  the  amount  used  is  read  off  from  the 
burette. 

The  fermentation  test  by  yeast  is  another  method  in  use  to  deter- 
mine the  presence  of  sugar.  As  a  quantitative  test  it  was  sug- 
gested by  Roberts,  and  its  accuracy  has  been  endorsed  by  Doremus.|| 
It  depends  upon  the  fact  that  by  fermentation  of  saccharine  urine 
all  the  sugar  is  converted  into  carbonic  acid,  water,  and  alcohol, 
and  consequently  the  urine  is  diminished  in  density,  and  each 
degree  of  density  lost  indicates  one  grain  of  sugar  to  the  fluid- 
ounce  of  saccharine  urine.  The  method  of  procedure  is  as  fol- 
lows. About  four  ounces  of  the  urine  are  put  into  a  twelve-ounce 
bottle,  and  a  lump  of  German  yeast  about  the  size  of  a  small 
walnut,  or,  if  this  cannot  be  had,  ordinary  brewer's  yeast,  is 
added.  The  bottle  is  then  covered  with  a  nicked  cork  (which 
allows  the  escape  of  carbonic  acid),  and  is  kept  in  a  warm  place 
to  ferment.  Beside  it  should  be  placed  a  closely-corked  four- 
ounce  vial  containing  some  of  the  same  urine  without  any  yeast. 
The  object  of  this  is  to  obviate  any  error  which  might  occur  were 
the  specific  gravity  of  the  urine,  before  and  after  fermentation, 
taken  at  different  temperatures.     In  about  twenty-two  hours  the 


*  Neubauer  and  Vogel,  op.  cit. 

f  Clinical  Society's  Transactions,  June,  1880;  London  Lancet,  July  10, 
1880. 

X  New  York  Medical  Record,  March  23,  1880. 
I  Medical  and  Surgical  Reporter,  April  16,  1880. 
||  Flint's  Manual  of  Urine,  p.  42. 


THE  miXE  AXD  DISEASES  OF  THE  TJRIXARY  ORGANS.     655 

fermentation  will  have  ceased.  The  two  vials  should  be  removed 
to  a  cool  place,  so  that  the  urine  may  acquire  the  temperature  of 
the  surrounding  air.  The  specific  gravity  of  the  two  specimens 
of  urine  should  then  be  taken,  and  their  difference  of  density,  as 
determined  by  the  urinometer,  indicates  the  number  of  grains  of 
sugar  contained  in  each  fluidounce  of  the  saccharine  urine. 

The  peculiar  fungus  which  forms  in  saccharine  urine  has  also 
been  studied  to  confirm  the  diagnosis  of  the  unnatural  ingredient. 

To  estimate  the  quantity  of  sugar,  various  ingenious  instru- 
ments have  been  employed.  Of  these,  the  polarizing  apparatus 
proposed  by  Clerget  and  made  by  Soleil,  the  color-tube  of  Garrod, 
or  the  polaristrobometer  of  Wild  would  seem  to  be  the  best. 

Inosite. — This  is  a  substance  belonging  to  the  group  of  sugars, 
and  occasionally  found  in  the  urine.  It  is  not  detected  in  health, 
and  is,  according  to  Cloetta,  the  observer  who  first  discovered  it 
in  urine,  associated  either  with  glucose  or  with  albumen,  but  it 
has  been  found  in  urine  containing  neither;  it  appears  to  be  de- 
rived from  the  glycogen  of  the  liver.  Inosuria  is  a  symptom 
rather  than  a  disease.*  The  characteristic  reaction  of  inosite  is 
exhibited  when  a  solution  of  the  substance  is  evaporated  with 
nitric  acid  nearly  to  dryness  on  platinum,  and  the  residue,  moist- 
ened with  a  little  hydrate  of  ammonium  and  a  solution  of  chloride 
of  calcium,  is  again  evaporated  to  dryness :  a  marked  rose-color 
appears, — which  does  not  happen  when  true  sugars  are  treated  in 
the  manner  described. 

Extractive  matters,  in  certain  diseased  conditions,  drain  off  from 
the  blood,  and  sometimes  in  large  quantity.  Owen  Rees,  some 
years  since,  dwelt  on  their  value  in  diagnosis,  and  suggested  the 
tincture  of  galls  as  their  test.f  Healthy  urine  is  scarcely  affected 
by  tincture  of  galls ;  the  blood-extractives  are  immediately  pre- 
cipitated by  it.  This  precipitate  must  not  be  confounded  with 
that  of  the  earthy  and  potassium  salts  which  is  thrown  down  from 
all  kinds  of  urine  after  the  lapse  of  five  or  ten  minutes,  by  the 
spirit  contained  in  the  tincture.  Should  albumen  be  present  in 
the  urine,  it  must  be  separated  by  boiling  and  filtration  before 
applying  the  test. 

*  Gallois,  De  l'lnosurie,  1864. 

f  London  Medical  Gazette,  1851,  New  Series,  vol.  xiii.  p.  136. 


656  MEDICAL    DIAGNOSIS. 

The  presence  in  the  urine  of  the  blood-extractives  indicates 
merely  the  escape  of  blood-material,  and  proves  the  existence  of 
congestion  or  inflammation  of  some  part  of  the  urinary  surfaces. 
Rees  has  pointed  out*  that  in  Bright's  disease  the  extractives  can 
be  found  in  the  urine  before  albumen  is  met  with,  and  also  that 
they  exist  after  the  albumen  has  disappeared:  thus,  on  the  one 
hand,  warning  us  of  the  approach  of  albuminuria,  and,  on  the 
other,  against  too  early  a  belief  in  convalescence;  for,  as  he  justly 
observes,  so  long  as  the  blood  is  losing  its  extractives  so  long  is 
the  patient  in  peril.  The  presence  of  the  extractives  also  enables 
us  to  diagnosticate  nephritic  irritation  from  renal  calculus,  before 
albumen,  blood,  or  pus  has  appeared.  It  is  highly  probable  that 
extractives  will  be  found  preceding  albumen  in  urine  in  most 
cases.  To  the  delicate  test  by  guaiacum  for  the  crystalloids  of  the 
blood,  which  has  been  used  to  detect  this  prealbuminuric  stage, 
we  shall  presently  more  particularly  refer. 

Albumen. — Urine  may  be  albuminous  from  admixture  with 
blood  or  pus,  or  from  transudation  of  the  albumen  of  the  serum 
of  the  blood  through  the  walls  of  the  vessels  of  the  kidneys. 
The  forms  of  albumen  in  the  urine  are  chiefly  serum-albumen 
and  paraglobuline.  Sometimes  the  albumen  appears  only  for  a 
short  time  in  the  urine;  at  other  times  it  is  permanent;  and  in 
accordance  with  the  length  of  its  stay  its  significance  varies.  But 
let  us  here  rather  examine  the  tests  announcing  the  presence  of  the 
foreign  substance. 

There  are  several  methods  enabling  us  to  ascertain  the  occur- 
rence of  albumen.     Of  these,  the  chief  are  : 

Heat,  which  coagulates  the  albumen ; 

Nitric  acid,  which  causes  a  white  precipitate; 

Corrosive  sublimate,  which  also  occasions  a  precipitate. 

The  fir.st  and  second  of  these  tests  are  the  most  convenient  and 
the  most  in  use;  but  they  must  be  employed  with  certain  precau- 
tions, and  care  must  be  taken  not  to  rush  to  a  conclusion  that 
albumen  is  present  until  several  sources  of  fallacy  have  been 
guarded  against.  For  instance,  the  application  of  heat  may  render 
the  fluid  thick  by  throwing  down  the  phosphates  instead  of  the 
suspected  albumen.     We  can,  however,  easily  avoid    being  led 

*  Guy's  Hospital  Keports,  3d  Series,  vol.  xiv.  p.  431. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.      657 

into  error  by  adding  nitric  acid,  which  causes  the  turbidity  to 
disappear,  if  it  be  owing  to  the  phosphates.  Again,  if  the  urine 
be  alkaline  and  the  quantity  of  albumen  small,  heat  will  not  pro- 
duce coagulation.  Hence  the  urine  must  be  rendered  slightly  acid 
before  heat  is  applied.  Acetic  acid,  which  does  not  precipitate 
albumen,  may  be  added  for  the  purpose.  A  highly  acid  urine 
behaves  like  an  alkaline  urine;  in  it,  too,  albumen  may  fail  to  be 
exhibited  by  heat. 

The  addition  of  nitric  acid  may  give  rise  to  a  precipitate  which 
is  not  albumen.  It  may  deposit  the  urates,  or  even  uric  acid.  But 
heat  here  is  the  touchstone.  The  boiling  urine  clears  quickly,  if 
the  opacity  be  not  caused  by  coagulated  albumen. 

Now,  as  both  the  heat  and  the  nitric  acid  test  may  lead  to 
wrong  conclusions,  if  trusted  to  exclusively,  we  must,  to  obviate 
sources  of  error,  in  every  case  employ  both.  The  best  method  of 
proceeding  is  to  boil  the  urine,  after  having  ascertained  it  to  be  of 
acid  reaction,  in  a  test-tube,  by  the  flame  of  a  spirit-lamp,  and  then 
to  add  the  acid.  Or  a  second  specimen  may  be  tested  according 
to  a  plan  proposed  by  Heller:  a  small  conical  glass,  about  one- 
third  full  of  urine,  is  held  in  an  inclined  position  in  the  left 
hand;  twenty  drops  of  nitric  acid  are  then  allowed  to  flow  grad- 
ually down  the  side  of  the  vessel ;  the  acid  collects  at  the  bottom, 
and  above  it  will  be  seen  an  accurately-defined  layer  of  coagulated 
albumen,  while  about  this  there  may  be  a  whitish,  ill-defined  cloud, 
consisting  of  urates.  From  the  depth  of  the  sharply-marked  cone 
we  may  estimate  the  amount  of  albumen.  When  it  is  faint,  whitish, 
and  only  about  2  to  3  millimetres  (0.078  to  0.118  inch)  high,  the 
albumen  is  less  than  J  per  cent.  When  the  zone  is  double  as  high, 
snow-white,  and  distinctly  to  be  recognized  without  using  a  black 
background,  albumen  is  present  in  the  quantity  of  J  to  \  per  cent. 
When  on  the  addition  of  the  acid  the  albumen  appears  lumpy, 
a  considerable  share  of  it  falling  to  the  bottom,  we  may  estimate 
that  it  is  present  to  the  amount  of  1  or  2  per  cent,  or  more. 

The  quantity  of  nitric  acid  used  must  be  neither  too  much  nor 
too  little.  A  large  amount  redissolves  the  albumen  ;  merely  a  drop, 
on  the  other  hand,  may  retard  instead  of  favoring  coagulation, 
which  then  does  not  take  place  even  when  the  urine  is  boiled.  In 
testing  for  albumen  by  means  of  heat  and  nitric  acid,  there  may  be 
no  immediate  response,  yet  after  a  few  hours  a  flocculent  precipi- 

42 


658  MEDICAL    DIAGNOSIS. 

tate  may  form  and  fall  to  the  bottom  of  the  tube.*     This  precipi- 
tate is  not  dissolved  on  again  applying  heat. 

Sometimes  urine  is  encountered  on  which  neither  the  heat  nor 
the  acid  test  yields  the  customary  result.  This  is  owing  to  its 
containing  a  modified  form  of  albumen.  Such  a  case  was  pub- 
lished by  Bence  Jones.f  No  coagulation  was  produced  by  heat, 
and  none  by  nitric  acid,  unless  the  urine  was  subsequently  heated 
and  permitted  to  cool.  The  solid  that  formed  on  cooling  dis- 
appeared on  heating.  The  substance  which  was  precipitated  by 
alcohol  was  the  hydrated  deutoxide  of  albumen.  The  patient 
was  laboring  under  mollities  ossium.  Bash  am  recommends  the 
tincture  of  galls  as  a  test  for  this  modified  form  of  albumen. 
Scherer,  too,  has  met  with  a  form  of  albumen  precipitable  from 
the  solution  containing  it  by  alcohol,  but  not  by  heat;  boiling 
causing  a  mere  turbidity.  Gowers|  notes  a  peculiar  kind  of  albu- 
men in  the  urine  that  is  soluble  at  the  temperature  of  boiling 
water,  heat  and  nitric  acid  producing  no  precipitate;  nor  does 
alcohol  in  moderate  quantity ;  while  a  moderate  quantity  of  nitric 
acid  throws  down  an  abundant  sediment  in  cold  urine.  It  may 
well  be  questioned  whether  there  are  not  a  number  of  albuminous 
forms  in  urine  in  diiferent  conditions, — some,  like  the  peptones, 
the  result  of  incomplete  digestion;  others,  like  paraglobulin,  de- 
rived from  the  blood. § 

Mehu  has  reeommended||  the  following  carbolic  acid  solution  as 
a  test  for  albumen  : 

Of  crystallized  carbolic  acid  and  commercial  acetic  acid,  each 
1  part  by  weight;  of  alcohol,  90  p.  c,  2  parts.  This  solution 
undergoes  no  change  by  keeping.  It  is  used  as  follows.  To  100 
grammes  of  urine  add  2  cc.  of  commercial  nitric  acid,  and 
thoroughly  mix.  Upon  the  addition  of  10  cc.  of  the  carbolic 
acid  solution  the  albumen  is  precipitated  in  white  flakes.  In 
testing  highly  albuminous  urine  or  albuminous  solutions  charged 
with  salts,  the  addition  of  nitric  acid  is  scarcely  required ;  nor  is 
it  for  ordinary  purposes  necessary  to  add  an  exact  quantity  of  the 

*  Andrew  Clark,  London  Hospital  Reports,  vol.  i.  p.  226. 
f  Philosophical  Transactions  for  1848.  J  Lancet,  July,  1878. 

§  Senator,  Virchow's  Archiv,  Bd.  lx.,  1879  ;  Brunton  and  Power,  St.  Barth. 
Hosp.  Kep.,  1877  ;  Neubauer  and  Vogel,  op.  cit.,  7th  edit.,  p.  384,  Am.  Transl. 
||  Archives  Generales  de  Medecine,  March,  1869,  p.  268. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.      659 

carbolic  acid  solution.  The  test  is  delicate,  and  may  be  employed 
for  quantitative  examinations,  as  it  precipitates  the  albumen  un- 
changed. This  is  collected  by  filtering,  washed  with  water,  later 
with  alcohol,  dried  at  110°  Cent.,  and  weighed.  But  the  accu- 
racy of  the  test  has  been  impugned  by  several  observers.  A 
mixture  of  equal  parts  of  acetic  and  carbolic  acids  is  stated  to 
make  a  more  trustworthy  solution.* 

Another  test  is  that  by  picric  acid.  "When  the  albumen  is 
abundant,  this  gives  striking  results.  A  few  drops  of  a  satu- 
rated solution  of  the  acid  are  added  to  the  urine  in  the  test-tube 
drop  by  drop ;  a  white  cloud  instantly  follows  the  admixture. 
Metaphosphoric  acid,  which  is,  however,  a  very  unstable  acid, 
is  said  to  be  a  very  delicate  test.f 

It  is  often  of  service  to  determine  the  exact  amount  of  albumen 
voided  with  the  urine.  This  may  be  accomplished  by  adding  a 
small  quantity  of  acetic  acid  to  a  weighed  quantity  of  urine,  which 
is  then  to  be  boiled.  The  precipitate  is  collected  on  a  filter, 
dried,  and  weighed.  An  easier  and  ordinarily  sufficiently  accu- 
rate method  consists  in  adding  a  small  quantity  of  acetic  acid  to  a 
specimen  of  urine,  boiling,  and  allowing  the  flaky  precipitate  to 
settle  in  the  test-tube,  taking  care  always  to  employ  test-tubes  of 
the  same  size;  the  proportion  of  precipitate  to  the  entire  bulk  is 
then  expressed  as  one-fifth,  one-eighth,  etc.,  as  the  case  may  be. 

Blood. — The  passage  of  blood  with  the  urine  constitutes  hsema- 
turia.  The  urine  is  of  a  red  color,  or  of  a  more  or  less  dingy  or 
smoky  hue,  and  deposits,  on  standing,  a  reddish-brown  or  a  dark 
coffee-ground  sediment.  If  much  blood  be  present,  small,  irregu- 
lar masses  are  seen  at  the  bottom  of  the  vessel. 

The  appearance  of  urine  containing  blood  is  therefore  not  uni- 
form. But,  whatever  the  look  to  the  naked  eye,  the  diagnosis  is 
at  once  rendered  certain  by  the  use  of  the  microscope.  And  only 
by  this  means  can  it  be  rendered  certain ;  for  urine  may  be  red 
or  black,  from  the  admixture  of  various  pigments  derived  from 
substances  swallowed  as  food  or  medicine,  or  belonging  to  the 
economy.  Thus,  beet-root,  some  kinds  of  strawberries,  logwood, 
and  rhubarb  impart  a  deep-red  color,  which  may  be  the  cause  of 
groundless  alarms;  or  urine  deeply  tinged  with  bile,  or  discolored 

*  Medical  Times  and  Gazette,  Sept.  1874. 

f  Grigg,  British  Medical  Journal,  May,  1S80. 


660  MEDICAL    DIAGNOSIS. 

by  fever,  may  be  thought  to  signify  the  occurrence  of  hemorrhage 
from  the  urinary  passages. 

The  chemical  tests  for  blood  are,  on  the  whole,  inferior  to  the 
microscopic  examination.  But  we  may  have  sometimes  to  resort 
to  them.  I  have  found  a  rough. test  in  the  addition  of  carbolic 
acid,  which  not  only  coagulates  the  albumen,  but  also  changes  the 
color  of  the  fluid.  It  does  not  produce  the  same  peculiar  reddish 
tinge  with  bile,  or,  so  far  as  I  have  tried,  with  any  other  sub- 
stance. The  guaiacum  test  is  regarded  as  very  accurate.  It  is- 
said  by  Mahomed  to  detect  infinitesimal  traces  of  blood,  or  rather 
its  characteristic  crystalloids,  when  neither  the  microscope  nor  the 
spectroscope  nor  the  nitric  acid  test  for  albumen  affords  any  in- 
dication of  their  presence.  It  is  especially  valuable  in  detecting 
the  prealbuminuric  stage  of  Bright's  disease;  in  which  haemoglo- 
bin appears  in  the  urine  before  albumen.*  The  test,  as  modified 
by  Stevenson,  consists  in  adding  to  a  few  drops  of  urine  in  a  small 
test-tube  a  drop  of  tincture  of  guaiacum  and  then  a  few  drops  of 
ozonic  ether.  The  mixture  is  agitated,  and  as  the  ether  collects  at 
the  top  it  carries  with  it  the  blue  color  produced  by  the  haemo- 
globin, leaving  the  urine  colorless  below.  If  saliva  or  a  salt  of 
iodine  be  present,  the  test  is  fallacious. 

But  the  microscope,  as  already  stated,  is  the  means  most  em- 
ployed. The  corpuscles  we  detect  with  it  are  not  always  of  uni- 
form appearance,  yet  they  are  never  collected  in  rouleaux.  But, 
after  having  found  blood  corpuscles  to  indicate  the  true  nature  of 
the  changed  hue  of  the  excretion,  the  questions  remain  to  be  solved, 
at  what  point  has  the  blood  been  poured  out?  Is  it  really  from 
the  urinary  organs?  and  if  it  be  from  them,  whence? — from  the 
kidneys,  from  the  bladder,  or  from  some  other  portion  of  the  tract? 
Again,  what  morbid  state  lies  at  the  root  of  the  hemorrhage? 

Now,  the  first  of  these  questions  must  always  be  answered  at 
the  onset.  Blood  may  flow  from  the  vagina  or  uterus  and  become 
mixed  with  the  urinary  secretion,  or  it  may  have  been  added  for 
purposes  of  deception.  In  the  former  case,  a  careful  inquiry  into 
the  state  of  these  organs,  or,  if  necessary,  a  digital  examination, 
will  eliminate  the  source  of  error;  in  the  latter,  drawing  off  the 
urine  by  the  catheter  will  detect  the  imposture.     When  we  have 

*  Medico-Chirurgical  Transactions,  1874. 


THE  "PEINE  AND  DISEASES  OF  THE  URINARY  ORGANS.      661 

fully  satisfied  ourselves  that  the  blood  is  derived  from  the  urinary 
organs,  the  next  point  to  be  ascertained — and  clinically  its  im- 
portance cannot  be  overrated — is,  whether  it  proceeds  from  the 
kidney  or  from  the  bladder.  To  determine  this,  we  have  not  only 
to  study  the  character  of  the  fluid  excreted,  but  also  to  investigate 
closely  all  the  conditions  of  the  accident. 

If  the  blood  come  from  the  bladder,  it  is  not  equally  diffused 
through  the  urine ;  the  fluid  discharged  is  at  first  clear  or  nearly 
so,  but  at  the  end  of  the  act  of  micturition  is  much  more  deeply 
colored,  or  pure  blood,  in  a  liquid  form  or  in  clots,  is  voided. 
Then,  too,  there  is  usually  pain  over  the  bladder,  with  a  frequent 
desire  to  pass  water,  and  a  stoppage  in  doing  so. 

When  the  blood  is  derived  from  the  kidney,  we  discover,  on 
the  one  hand,  pain  in  the  lumbar  region,  and  other  symptoms 
pointing  to  the  affected  organ,  the  existence  of  albumen  in  con- 
siderable quantities  in  the  urine,  or  the  passage  of  gravel.  Clots 
are  not  encountered  in  renal  hemorrhage,  except  when  the  blood 
coagulates  in  the  infundibulum  or  the  ureter  and  is  gradually 
forced  downward.  Such  clots  are  of  a  whitish  color,  and  generally 
of  cylindrical  shape.  In  their  passage  toward  the  bladder  and  out 
of  the  urethra  they  become  often  the  source  of  distressing  pain. 
They  are  very  significant,  yet  they  are  not  absolutely  pathogno- 
monic of  renal  hemorrhage;  for  coagula  formed  in  the  bladder 
may  be  retained  there  for  some  time,  and  lose  their  color  before 
they  are  expelled.  Sometimes  we  meet  with  little  solid  or  gelati- 
nous fibrinous  coagula  which  bespeak  simply  localized  fibrinous 
exudation  from  some  part  of  the  urinary  passages. 

Aid  in  diagnosis  may  be  derived  from  the  study  of  the  shape 
of  the  clots,  which  for  this  purpose  should  be  floated  out  in  water. 
According  to  Hilton,*  they  will  oftentimes  be  exact  moulds  or  casts 
of  the  cavity  in  which  the  blood  was  effused.  Thus,  for  instance, 
coagula  formed  within  the  bladder  have  a  somewhat  irregular, 
circular  outline,  and  are  flattened  in  shape,  with  bevelled  and 
serrated  edges. 

The  use  of  the  microscope,  furthermore,  affords  most  valuable  aid 
in  the  differential  diagnosis.  The  epithelium  which  is  mixed  with 
the  blood  from  the  kidney  is  not  flat  and  in  scales,  like  that  from 

*  Guy's  Hospital  Keports,  3d  Series,  vol.  xiii.  p.  19  et  seq. 


662  MEDICAL    DIAGNOSIS. 

the  bladder,  but  small  and  more  or  less  round.  Hofmann  and 
Ultzmann  direct  attention  to  the  various  size  of  the  corpuscles  as 
significant  of  the  hematuria  which  attends  parenchymatous  affec- 
tions of  the  kidney  and  bladder  ;  quite  small,  even  dust -like  blood 
corpuscles  are  met  with.  Sometimes  the  blood  globules  are  seen  to 
be  collected  on  casts  that  have  been  moulded  within  the  renal  tubes. 
These  blood-casts  warrant  an  absolute  conclusion  as  to  the  source 
of  the  hemorrhage.  But  they  do  not  always  occur ;  and  their 
absence,  therefore,  is  not  so  valuable  a  proof  as  their  presence. 

Although,  then,  there  is  no  one  constant  and  unequivocal  sign 
of  either  renal  or  vesical  hemorrhage,  we  may  generally  arrive, 
by  care,  at  a  correct  knowledge  of  the  source  whence  the  blood 
proceeds.  In  perplexing  cases  we  should  obtain  specimens  of 
urine  for  examination  in  the  manner  recommen-ded  in  the  early 
pages  of  this  chapter. 

But  let  us  suppose  that  the  origin  of  the  flow  has  been  satisfac- 
torily settled :  it  still  remains  to  determine  what  is  the  probable 
cause  of  the  bleeding.  Here,  too,  trustworthy  knowledge  is  not 
to  be  obtained,  save  by  careful  analysis  of  the  group  of  symptoms. 

Renal  hcematuria. — When  of  renal  origin,  the  hsematuria  is  often 
due  to  an  irritation  or  an  inflammation  of  the  kidneys  produced 
by  some  poison  escaping  out  of  the  system  through  this  channel, 
as  in  scarlatina  and  in  other  idiopathic  diseases  in  which  the  phe- 
nomena of  acute  desquamative  nephritis  show  themselves.  Here 
we  have  the  history  of  the  malady,  and  the  presence  of  tube-casts 
and  of  a  considerable  amount  of  albumen  in  the  urine,  to  explain 
the  meaning  of  the  hemorrhage.  The  blood  is  derived  from  the 
engorged  and  ruptured  Malpighian  corpuscles. 

A  congestion  of  the  kidneys  of  analogous  nature,  and  leading  to 
the  same  consequences,  is  occasionally  encountered  in  typhus  fever, 
in  smallpox,  in  malignant  measles,  and  in  acute  rheumatism.  Ir- 
ritant medicines,  too,  such  as  turpentine  and  can th arid es,  cause 
congestion  and  bloody  urine ;  and  so  do  strains  and  blows  on  the 
back.  In  all  these  varied  circumstances,  a  knowledge  of  the  his- 
tory of  the  case  and  a  careful  survey  of  its  symptoms  render  the 
diagnosis  positive. 

Renal  hsematuria  of  more  chronic  character  is  generally  due  to 
cancer  of  the  kidney;  to  cystic  degeneration;  to  ulceration  within 
the  pelvis  of  the  organ ;  or  to  irritation,  with  or  without  ulcera- 


THE  URIXE  AXD  DISEASES  OF  THE  URINARY  ORGANS.     663 

tion,  set  up  by  a  calculus.  In  the  first  of  these  affections  there  is 
nothing  peculiar  in  the  urine  to  point  out  the  source  of  the  hema- 
turia until  the  disease  is  far  advanced,  when  pus,  and  sometimes 
disorganized  cancerous  tissue,  may  be  detected  in  the  sediment. 
The  manifestations  of  cystic  degeneration  are  uncertain  unless  we 
can  detect  a  large  tumor;  and  the  signs  of  a  non-calculous  pyelitis 
are  not  sufficiently  definite  to  enable  us  to  distinguish  this  rare 
malady  with  anything  like  accuracy.  The  existence  of  a  calculus 
— one  of  the  most  common,  if  not  the  most  common,  of  the  agents 
producing  hematuria — is  indicated  as  the  source  of  the  hemor- 
rhage by  localized  pain  and  by  the  bleeding  having  followed 
active  exertion,  or  a  jar  of  the  body  from  a  fall,  and  by  its  recur- 
ring from  time  to  time  under  circumstances  like  those  just  men- 
tioned, favorable  to  the  disturbance  of  a  calculus  lodged  in  the 
kidney.  The  presumption  of  this  being  the  reason  of  the  repeated 
bleeding  is  converted  almost  into  certainty  if  on  any  occasion  a 
stony  concretion  have  been  expelled.  Simon  has  catheterized  the 
ureters  and  thus  determined  renal  calculi ;  but  this  is.  not  a  pro- 
cedure easy  to  imitate. 

There  has  been  described,  under  the  name  of  paroxysmal  or 
intermittent  hcematuria,  a  disease  which  differs  from  ordinary  renal 
hemorrhage  in  that  in  the  latter  the  urine  is  not  only  coagulable  by 
heat  and  nitric  acid,  but  also  contains  blood  corpuscles  ;  while  in 
the  former,  although  coagulable  by  heat  and  nitric  acid,  it  exhibits 
very  few  or  no  'blood  corpuscles,  and  the  coloring-matter  is  not 
deposited  on  standing.  Besides,  the  urine  shows  an  increased 
proportion  of  urea.  According  to  Greenhow,*  crystals  of  oxalate 
of  lime  are  constantly  passed  during  a  paroxysm  and  are  absent 
at  other  times.  This  affection  is  unattended  by  any  permanent 
lesion  of  the  kidneys.  It  is  paroxysmal  in  form,  and  is  not  of 
malarious  origin,f  though  it  is  clear  that  it  is  often  confounded 
with  hemorrhagic  malarial  fever,  with  which  it  has,  as  we  shall 
farther  on  see,  many  symptoms  in  common.  The  disease  is 
ushered  in  by  rigor,  which  is  followed  by  only  an  imperfect  hot 
stage,  and  more  rarely  by  sweating.  The  urine  voided  is  of  a 
deep  blood-color,  and  within  an  hour  or  two,  perhaps,  changes 

*  Transactions  of  Clinical  Society,  1868,  vol.  i. 

f  Vide  Greenhow,  lot.  cit. ;  also  Pavy,  Trans,  of  Path.  Soe.  of  Lond.,  vol. 
xviii.,  and  Druitt,  Medical  Times  and  Gazette,  vol.  i.,  1873. 


664  MEDICAL    DIAGNOSIS. 

Buddenly  to  a  pale  straw-color.  The  etiology  of  the  disease  is 
unknown.  In  those  predisposed,  brain-worry  brings  on  attacks; 
rest  and  food  may  prevent  them. 

There  is  also  a  form  of  hematuria  which  is  endemic,  and  de- 
pends upon  the  presence  of  a  parasite  (Bilharzia  hsematobia).  It 
prevails  in  the  Mauritius,  certain  parts  of  the  Cape  of  Good 
Hope,  Natal,  Egypt,  and  Brazil.  The  parasite  inhabits  mainly 
the  small  vessels  of  the  mucous  membrane  of  the  urinary  passages 
and  the  kidneys,  and  it  gains  access  to  these  parts  chiefly  during 
the  act  of  bathing  in  the  rivers.  Persons  affected  with  the  Bil- 
harzia luematobia  are  often  observed  to  pass  small  renal  calculi  of 
oxalate  of  lime  having  for  their  nuclei  the  ova  of  this  parasite.* 

Further,  there  is  a  form  of  luematuria  peculiar  to  infants.  This 
has  been  described  by  Parrot,  f  under  the  name  of  renal  tubal  hce- 
maturia,  and  is  characterized  by  hematuria  and  the  accumula- 
tion in  the  tubules  of  the  kidney  of  the  red  globules  of  the  blood, 
and  by  a  bronze  discoloration  of  the  skin,  and  cephalic  symptoms. 

Besides  these  causes,  renal  hemorrhage  may  result  from  an 
altered  state  of  the  blood.  Haematuria  of  this  kind  is  encoun- 
tered in  purpura  and  scurvy. 

Vesical  hematuria. — To  consider  now  vesical  haematuria.  One 
source  to  which  it  may  be  owing  is  a  congestion  of  the  bladder,  as 
witnessed  in  fevers  of  a  low  type.  Another  is  irritant  diuretics. 
Another  is  blood-effusion  from  purpura  or  the  hemorrhagic  diath- 
esis. Yet  another  is  inflammation,  whether  acute  or  chronic, 
and  whether  of  traumatic  origin  or  brought  on  by  a  stone.  In 
most  of  these  contingencies  the  history  of  the  case  and  the  local 
symptoms  establish  the  diagnostic  distinctions;  in  arriving  at 
which  we  are  often  materially  aided  by  the  introduction  of  a 
sound  into  the  bladder.  It  has  been  claimed  for  the  endoscope 
that  it  also  a-.-ists  greatly  in  the  diagnosis;  but  this  instrument 
has  not  answered  the  expectations  that  were  entertained  of  it. 

Another  form  of  hemorrhage  from  the  bladder  is  dependent 
upon  tumor  or  malignant  growths  on  its  mucous  coat.  Generally 
these  are  attended  with  pain,  with  a  constant  desire  to  empty  the 
viscus,  and  with  considerable  emaciation  and  a  general  cachectic 

*  Geo.  Harley,  in  Medico-Chirurgical  Transactions,  vol.  xlvii.  p.  56,  and 
vol.  lii.  p.  379. 

j  Archives  de  Physiologie,  Sept.  1873. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.      665 

condition.  The  fluid  which  is  passed  frequently  contains  pus, 
and,  as  the  malady  advances,  from  time  to  time  large  quantities 
of  blood.  Yet  it  is  not  a.  little  singular  that  the  appearance  of 
the  blood  in  the  excretion  may  be  the  first  sign  of  disturbance.* 

"Vesical  hematuria,  more  frequently  than  renal,  occurs  as  a 
vicarious  discharge.  Persons  who  are  subject  to  bleeding  piles 
lose  blood  occasionally  from  the  bladder,  instead  of  from  the 
rectum.  But,  in  obscure  cases  of  this  kind,  before  arriving  at 
a  definite  conclusion  it  is  necessary  to  bear  in  mind  that  some 
writers,  Thudichum  prominently  among  them,  believe  that  true 
vesical  haemorrhoids  are  not  uncommon. 

Blood  may  be  discharged  from  other  parts  of  the  urinary  appa- 
ratus as  well  as  from  the  bladder  or  the  kidneys.  It  may  come 
from  the  prostate  gland  or  the  urethra.  Now,  in  either  case  the 
bleeding  is  usually  very  profuse,  and  large  quantities  of  blood  are 
passed  pure,  or  at  first  unmixed  with  urine.  Besides,  there  are 
local  signs  of  disease  of  these  parts,  furnishing  important  points 
of  discrimination.  But  this  subject  cannot  be  here  pursued :  it 
belongs  rather  to  the  domain  of  surgery  than  to  that  of  medicine. 

Such,  then,  are  the  various  conditions  under  which  hematuria 
may  be  noticed.  As  regards  its  gravity,  it  is  evident  that  this 
depends  less  upon  the  hemorrhage  itself  than  upon  the  disorder 
of  which  the  hemorrhage  is  a  symptom.  The  flow  of  blood  in 
itself  is  very  rarely  fatal.  One  of  the  worst  consequences  it  may 
entail  is  the  retention  of  a  clot  which  serves  as  a  nucleus  for  the 
formation  of  a  calculus. 

Pus. — Urine  containing  pus  deposits  an  opaque  creamy  sedi- 
ment or  a  glairy  mass,  is  generally  alkaline,  and  always  slightly 
albuminous.  If  the  deposit  be  agitated  with  an  equal  quantity  of 
liquor  potasses,  a  dense  gelatinous  mass  results.  This  is  the  chem- 
ical test  for  pus.  But  it  is  a  clumsy  one,  compared  with  the  rapid 
and  absolute  diagnosis  of  the  pus  corpuscles  by  means  of  the  mi- 
croscope ;  this  is  especially  valuable  where  the  amount  of  pus  is 
so  small  as  to  form  no  deposit. 

A  deposit  of  phosphates  may  be  mistaken  for  pus  ;  a  few  drops 
of  acetic  acid  clear  it  up,  but  do  not  influence  pus.     Sometimes  a 


*  A  case  in  point  is  reported  by  Todd,  Case  XI.,  Lectures  on  Urinary 
Diseases. 


we 


MEDICAL    DIAGNOSIS. 


large  amount  of  mucus  is  mixed  with  the  purulent  sediment,  or  a 
deposit  due  wholly  to  the  former  ingredient  is  so  considerable  that 
it  is  mistaken  for  pus.  Yet  the  mucous  deposit  shows  distinct 
points  of  difference :  it  is  less  dense,  and  collects  more  in  clouds 
at  the  bottom  of  the  vessel ;  and  it  does  not  under  any  test  show 
albumen.  Again,  the  microscope  is  a  valuable  means  of  discrimi- 
nation. In  place  of  pus  corpuscles, — those  well-known  granular 
spherical  bodies  with  their  multiple  nuclei, — quantities  of  epithe- 
lium are  always  seen  to  be  entangled  in  the  transparent  mucus, 
and  the  action  of  acetic  acid  develops  the  filaments  of  mucin. 
Sometimes,  also,  there  are  thin  flakes  of  cylindrical  bodies,  unlike 
any  appearance  exhibited  by  pus. 

Yet  when  the  urine  is  strongly  ammoniacal,  even  the  micro- 
scope does  not  furnish  a  certain  test ;  for  the  salts  of  ammonia 
obliterate  the  distinctive  pus  globules  and  convert  pus  into  a 
slimy  mass,  in  which  nothing  but  the  nuclei  may  be  distinguish- 
able. 

Fig.  45. 


Pus  corpuscles;  those  at  the  lower  part  of  the  field  exhibit  the 
action  of  acetic  acid  on  the  corpuscles. 


The  occurrence  of  pus  in  the  urine  is  a  sign  of  suppuration 
somewhere  in  the  genito-urinary  system,  or  a  proof  that  an  ab- 
scess has  opened  into  and  is  being  discharged  through  this  channel. 
But  as  to  the  exact  seat  of  the  formation  of  the  abnormal  product, 
its  existence  in  the  urine  affords  no  clue.  To  some  extent,  how- 
ever, we  can  judge  of  this  by  the  microscopical  appearance  of  the 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.      667 

corpuscles.  When  these  are  round  and  well  developed,  with  their 
characteristic  nuclei  readily  brought  out  by  acetic  acid,  they  gen- 
erally have  their  origin  in  a  catarrhal  inflammation  of  the  mucous 
membrane,  especially  of  the  bladder.  On  the  other  hand,  as 
Vogel  points  out,  pus  corpuscles  of  irregular  contour,  exhibiting 
irregular  nuclei  when  treated  with  acetic  acid,  or  an  ill-defined 
granular  mass,  consisting  of  irregularly-shaped  pus  corpuscles  and 
partially-destroyed  cells,  indicate  the  probable  existence  of  deep- 
seated  suppuration,  ulceration,  or  tubercular  disease. 

Fat. — Fatty  matter  may  occur  in  the  urine  in  various  forms 
and  in  different  conditions.  It  may  be  found  in  the  shape  of 
globules,  when  oil  or  milk  has  been  added  to  the  urine  for  pur- 
poses of  deception,  or  when  the  former  article  has  been  swallowed 
for  some  time  in  considerable  quantities,  as  for  instance  during 
the  administration  of  cod-liver  oil.  It  is  also  encountered  in 
globules  of  varying  size,  either  free,  in  cells,  or  in  tube-casts,  as 
in  fatty  degeneration  of  the  kidneys. 

In  some  cases  it  is  met  with  in  a  molecular  state,  imparting  to 
the  urine  a  milky  appearance,  to  which  the  name  chylous  urine 
has  been  given.  The  cause  of  this  milky  urine  is  not  positively 
known.  Beale  considers*  that  the  condition  does  not  depend 
upon  any  permanent  morbid  change  in  the  secreting  structure  of 
the  kidney,  and  that  the  chylous  character  of  the  urine  is  inti- 
mately connected  with  the  absorption  of  chyle;  but  precisely  how 
the  urine  acquires  that  character  is  uncertain.  It  may  continue 
for  years  without  impairment  of  the  general  health,  being  always 
perceptibly  increased  by  exercise. f 

The  tests  for  fat  are  its  solubility  in  ether,  and  its  microscopical 
characters.  Lee  and  Atlee  have  pointed  out|  an  illusory  detec- 
tion of  fat.  They  found,  in  testing  a  specimen  of  urine,  that  the 
ether  rose  to  the  top  so  charged  with  matter  as  to  resemble  a  half- 
liquid  pomade.  Separated  by  a  pipette  and  spontaneously  evapo- 
rated, it  left  a  dirty-whitish  greasy  mass.     A  careful  examination 


*  Kidney  Diseases  and  Urinary  Deposits,  3d  edit.,  p.  309. 

-j-  See  cases  of  the  disorder  in  the  papers  of  Bence  Jones,  Medico-Chirurgical 
Transactions,  1850-53 ;  of  Gubler,  Gazette  Medicale  de  Paris,  1858 ;  and  of 
Isaacs,  Transactions  of  New  York  Academy  of  Medicine,  vol.  ii.  ;  also  Beale, 
Kidney  Diseases  and  Urinary  Deposits,  and  Roberts  on  Urinary  Diseases. 

%  Amer.  Journ.  of  Med.  Sci.,  April,  1869,  p.  357. 


668  MEDICAL    DIAGNOSIS. 

of  this  residue  showed  that,  instead  of  consisting  of  fatty  acids,  it 
contained  nothing  but  the  normal  constituents  of  the  urine,  for  it 
was  soluble  in  water,  reappearing  as  normal  urine.  It  was  then 
ascertained  that  almost  any  urine  will  form  an  emulsion  when 
violently  agitated  with  ether,  especially  if  the  ether  contain  a 
small  amount  of  alcohol.  When,  therefore,  ether  appears  to  dis- 
solve out  fatty  matter  from  urine,  the  ethereal  solution  should 
be  separated,  and  allowed  to  evaporate  spontaneously,  and  if  the 
residue  be  soluble  in  water  it  cannot  be  held  to  contain  fat. 

When  passed  in  large  amounts,  fat  may  be  evident  to  the 
unassisted  eye.  But  there  is  no  certainty  of  its  presence  unless 
the  sediment  be  examined  chemically  and  microscopically.  The 
opalescence  of  urine  caused  by  a  sediment  of  urates  has  been  mis- 
taken for  that  from  oily  matter,  and  so  also  has  been  the  pellicle 
which  often  forms  on  urine,  and  which  consists  not  of  fat,  but 
of  vibriones,  fungi,  and  crystals  of  the  triple  phosphates.  The 
"kyestein"  pellicle  observed  in  the  pregnant  state  is  of  similar 
kind,  though  some  oily  matter  may  enter  into  its  composition. 

A  urine  which  spontaneously  coagulates  soon  after  being  voided, 
owing  to  fibrin,  a  fibrinuria,  is  very  uncommon  except  in  the  Isle 
of  France  and  in  Brazil.  A  thick  urine  may  be  due  to  pus  dis- 
solved in  alkalies,  as  in  certain  bladder  affections.  But  the  thick 
matter  is  at  once  greatly  thinned  by  water,  and  on  the  addition  of 
acetic  acid  a  white  precipitate  of  alkaline  albuminate  falls.* 

Sediments. — In  connection  with  the  ingredients  of  the  urine, 
the  nature  of  the  urinary  sediments  has  been  discussed,  and  it  has 
been  insisted  that  they  cannot  be  accurately  determined  save  by 
a  microscopical  examination.  I  shall  here  only  group  together 
their  general  characteristics : 

1.  A  light  and  flocculent  cloudy  deposit  is  commonly  mucus, 
entangling  epithelial  cells,  bacteria,  or  spermatozoa. 

2.  A  dense,  abundant,  white  deposit  is  generally  composed  of 
urates  or  phosphates ;  but  it  may  be  pus  or  extraneous  matter. 

3.  A  yellow  or  pink  deposit  is  almost  always  due  to  urates. 

4.  A  granular  or  crystalline  deposit,  of  reddish  or  dark- brown 
color  and  small  in  quantity,  is  uric  acid. 

5.  A  dark,  sooty  or  dingy-red  deposit  is  blood. 

*  Hofmann  and  Ultzmann,  op.  cit. 


THE  UEINE  AND  DISEASES  OF  THE  URINARY  ORGANS.       669 

The  following  table  may  serve  a  useful  purpose,  in  showing 
how  both  the  sediments  and  the  soluble  urinary  ingredients  are 
affected  by  the  reagents  commonly  employed : 


Table  exhibiting  the  Action  of  the  Main  Eeagents  employed  in 
the  Examination  of  the  Urine. 


Specific  Grav- 

ITY 


High. 


Heat. 


Low 

Throws  down  de- 


posit     I  Insoluble  in  acid 

Dissolves  deposit  s  Urates. 

Does  not  dissolve  j  Uric  acid, 

deposit \  Phosphates. 


Urine    high-col-   e  Increase  of  urea, 

ored \      uric  acid,  etc. 

Urine  pale Diabetes. 

Urine    high-col-   r  Certain  forms  of 
ored  or  normal.  \     Bright's  disease. 

Urine  pale Excess  of  water. 

f  Soluble  in  acid...       Phosphates. 
Albumen. 


Nitric  Acid....  -I   Dissolves 


Precipitates , 


I   Quickly <   Albumen. 

More  gradually- 


Uric  acid. 

Crystals   of    ni- 
trate of  urea. 


Earthy  phos- 
phates. 

Alkaline  phos- 
phates. 

Oxalates. 

With  heat 


Causes  decompo- 
sition under  ef- 
fervescence  


Without  heat.. 


Urea  decomposed 
into  carbonate 
of  ammonium. 

Carbonate    of 
calcium. 

Uric  acid. 


Hydrochloric 
Acid 


Precipitates <   Uric  acid. 


Transforms. 


Sulphuric 
Acid 


Detects,  by  vio- 
let change  of 
color 


Changes  color  of 
urine 


Urates  into  uric 
acid. 

Uroxanthin  or 
indican. 

Brown <   Urohajmatin. 

Crimson  or  violet 
(if  sugar  have 
been  added).... 

Violet \   Indican 


Biliarv  acids. 


670 


MEDICAL   DIAGNOSIS. 


Table  exhibiting  the  Action  of  the  Main  Reagents  employed  in 
the  Examination  of  the  Urine—  Continued. 


Acetic  Acid. 


'  Precipitates  de- 
posit (not  solu- 
*      .  v  „  J.   Mucus, 

ble  in  excess  01 

the  acid) , 


Liquor  Po- 
tass.e 


f  _      .  ....  .  f  Earth  v  phos- 

Precipitates s  J 

l       phates. 

On  boiling,  turns   t  gugar> 

urine  brown...  \ 


Dissolves. 


I 


Liquor  Ammo- 
ni.e 


Sol.  of  Chlor. 
of  Barium  ... 


Uric  acid. 

Deposits  of  urates. 

Forms  gelatinous    r 

{   Pus. 
mass (. 

■n      .  ..  ,  (  Earthy  phos- 

Precipitates \         , 

I       phates. 

Dissolves 


Precipitates. 


ph 
<   Cystine. 

f  Deposit  soluble      f  Phosphates. 

in  free  acid.        I 

Deposit  insoluble   ( 

Sulphates. 


Titrate  of  .  . 

■l   Precipitates. 
Silver >  ^ 


Alkaline  phos- 
phates. 


in  acids. 

f  Yellow    deposit, 
soluble   in    ni- 
tric   acid    and 
ammonia. 
White     deposit,    r 
insoluble  in  ni-   | 

trie    acid,    but  j   Chloride    of    so- 
soluble  in  am-  dium- 
monia.                  [_ 

j   Precipitate? <   Albumen. 

Dissolves -j  Hippuric  acid. 

Does  not  dissolve  <    Uric  acid. 
|  Dissolves j  Fat. 

URINARY  ORGANS. 

Diseases  of  the  Kidney  of  which  Pain  is  a  Prominent  Symptom. 

This  oroup  embraces  acute  inflammation  of  the  kidney,  and 
those  painful  affections  classed  under  the  term  nephralgia. 


Alcohol  or 
Ether 


Ether, 


THE  trilINE  AXD  DISEASES  OF  THE  TJEIXARY  OEGANS.      671 

Nephritis. — Acute  inflammation  of  the  kidney  is  chiefly  ob- 
served in  old  persons  and  in  damp  climates.  It  may  be  occa- 
sioned by  an  attack  of  acute  rheumatism,  by  direct  violence  to  the 
organ,  or  by  the  irritation  of  a  calculus ;  but  probably  its  most 
frequent  cause  is  exposure. 

It  begins  with  a  chill,  soon  followed  by  fever.  The  pulse  is 
small  and  hard,  the  skin  is  frequently  dry.  There  are  nausea 
and  vomiting,  and  at  times  diarrhoea  with  tenesmus.  The  urine 
is  voided  drop  by  drop ;  it  is  red,  and  may  contain  blood.  The 
patient  complains  of  pain  in  the  renal  region,  sometimes  dull,  at 
other  times  sharp  and  lancinating,  and  augmented  by  pressure  and 
by  moving.  The  pain  is  not  limited  to  the  kidney,  but  radiates 
to  the  diaphragm  and  to  the  bladder.  With  it  are  often  asso- 
ciated numbness  of  the  thigh  of  the  affected  side  and  retraction 
of  the  testicle. 

The  disease  may  occur  in  both  kidneys ;  yet  it  rarely  affects 
more  than  one.  It  lasts  from  one  to  three  weeks,  and  generally 
terminates  in  resolution.  But  it  may  lead  to  suppuration  and 
disorganization  of  the  organ. 

The  disorder  is  recognized  by  the  pain,  the  fever,  the  retraction 
of  the  testicle,  and  the  appearance  of  the  urine.  It  differs  from 
an  attack  of  colic  by  the  signs  of  disturbance  of  the  urinary 
organs,  by  the  seat  of  the  pain,  and  by  the  fever;  from  rheumatic 
pains  in  the  back,  by  the  former  of  these  symptoms.  Then,  in 
lumbago  we  rarely  find  much  febrile  excitement,  nor  are  there 
nausea  and  vomiting,  or  numbness  along  the  course  of  the  an- 
terior crural  nerve;  but,  on  the  other  hand,  the  pain  is  much 
more  influenced  by  movements,  especially  by  stooping  and  such 
other  motions  as  call  the  muscles  of  the  back  into  play.  Con- 
gestion of  the  kidneys  is  distinguished  from  inflammation  by  its 
affecting  both  sides,  by  the  absence  of  protracted  or  severe  pain, 
and  by  the  comparatively  slight  derangement  of  the  urinary  func- 
tions. Further,  the  congestion  is  not  idiopathic,  and  we  can  gen- 
erally trace  it  to  the  swallowing  of  some  irritating  substance,  or  to 
the  poison  of  a  febrile  malady,  such  as  smallpox  or  typhus. 

Chronic  nephritis,  if  such  a  disease  really  exist  irrespective  of 
the  forms  of  it  associated  with  albuminous  urine  and  belonging 
therefore  to  Bright's  disease,  is  so  ill-defined  and  uncertain  a 
malady  that  it  has  no  signs  which  positively  announce  its  presence. 


672  MEDICAL    DIAGNOSIS. 

Nephralgia. — Severe  pain  in  the  kidney,  unconnected  with 
inflammation  of  the  organ,  is  ordinarily  caused  by  the  passage  of 
a  calculus.  In  such  cases  we  have  all  the  symptoms  of  acute  in- 
flammation, save  the  fever,  although  passing  elevations  of  temper- 
ature are  not  uncommon;  the  pain,  too,  is  much  more  violent,  and 
ends  as  suddenly  as  it  began.  With  reference  to  the  diagnosis, 
the  complaint  may  be  confounded  with  the  same  maladies  as  ne- 
phritis, and  the  differences  are  identical  as  between  nephritis  and 
the  ailments  resembling  it,  except,  of  course,  that  we  must  leave 
out  of  consideration  any  indications  afforded  by  febrile  signs. 
Nephralgia  exhibits  a  great  similarity  to  colic;  but  this  has 
already  been  discussed  at  some  length  ;  and  in  particular  cases 
we  are  often  much  aided  by  the  knowledge  that  in  "  renal  colic" 
our  patient  has  on  a  former  occasion  passed  renal  concretions. 

The  amount  of  pain  varies  according  to  the  magnitude  of  the 
stone  and  its  character.  As  a  rule,  calculi  composed  of  oxalate  of 
lime  give  rise  to  most  pain.  We  may  distinguish  them  by  their 
roughness  and  irregularity,  and  their  brown  or  dark-gray  color ; 
those  of  uric  acid  and  urates  are  reddish  and  much  softer,  and  not 
jagged,  and,  unlike  calculi  consisting  of  the  salts  of  lime,  are  com- 
bustible on  platinum  foil,  leaving  a  mere  trace  of  residue,  while 
the  oxalate  of  lime  calculus  leaves  considerable  residue,  and  is 
soluble  in  mineral  acids  without  effervescence.  Calculi  of  the 
mixed  phosphates  are  white,  very  brittle,  soluble  in  acids,  insoluble 
in  alkalies,  and  fuse  in  the  blow-pipe  flame.  The  mixed  phos- 
phates rarely  form  a  stone  entirely,  being  often  only  an  incrustation 
around  a  blood-coagulum  or  a  foreign  body,  or  having  a  kernel  of 
uric  acid.  Indeed,  the  majority  of  phosphatic  stones  have  uric  acid 
centres,  while  calculi  of  uric  acid  or  its  salts  possess,  as  a  rule,  the 
same  composition  throughout ;  calculi  of  oxalates  have  often  a 
nucleus  of  uric  acid  and  a  crust  of  phosphates.  Xanthine  and 
cystine  are  the  rarer  constituents  of  stones.  The  former,  like  uric 
acid  and  the  ammonium  and  sodium  urates,  is  consumed  by  heat, 
and  burns  without  visible  flame,  but  the  murexide  test  exhibits 
an  orange-yellow  color;  cystine  burns  with  a  bluish-white  flame, 
emitting  an  odor  like  burning  fat,  and  the  powder  is  soluble  in 
dilute  ammonia. 

As  already  stated,  we  have  in  the  severity  of  the  pain  a  sign 
indicative  of  the  nature  of  the  case.     Still,  there  are  states  in  which 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGAXS.    673 

paroxysms  of  pain  referred  to  the  neighborhood  of  the  kidney 
are  attributable  to  far  other  causes  than  the  passage  of  a  calculus. 
Leaving  out  of  consideration  that  doubtful  disease,  pure  neuralgia 
of  the  kidney,  we  find  a  few  affections,  very  rare,  it  is  true,  which 
closely  simulate  the  passage  of  a  renal  calculus. 

The  first  of  these  is  the  pain  occasioned  by  an  inflamed  and 
ulcerated  ureter.  Todd  relates  a  case  of  the  kind.*  The  patient 
had  severe  attacks  of  lancinating  pain,  referred  to  the  right  loin, 
lasting  for  weeks,  and  accompanied  by  constant  and  intractable 
vomiting.  The  urine  contained  pus  in  varying  quantity,  but 
neither  blood  nor  calculous  matter  could  be  detected.  At  one 
time  he  continued  free  from  any  paroxysm  for  four  years.  After 
death  the  most  careful  search  was  made  for  a  calculus,  but  none 
could  be  discovered.  The  ureter  of  the  right  side  was  thickened 
throughout  the  greater  part  of  its  course,  and  deposits  of  lymph 
adhered  to  its  mucous  membrane.  A  somewhat  similar  train  of 
phenomena  may  occur  from  an  irritation  or  inflammation  of  the 
ureter,  caused  by  the  poison  of  rheumatism  or  gout,  although  the 
paroxysms  of  pain  are  apt  to  be  neither  so  severe  nor  of  so  long 
duration. 

Another  morbid  condition  closely  resembling  the  passage  of  a 
renal  calculus  may  result  from  malarial  poison.  How  close  this 
resemblance  may  be,  the  following  case  will  show : 

A  soldier,  twenty-four  years  of  age,  of  fair  complexion,  and 
evidently  of  strong  constitution,  Avas  seized  rather  suddenly  with 
pain  over  the  left  kidney.  The  loin  was  sensitive  to  the  touch, 
and  appeared  somewhat  red  and  swollen.  The  skin  was  hot ;  the 
pulse  100.  The  urine  was  not  found  to  be  abnormal,  though  con- 
taining a  reddish  coloring-matter.  The  pain  continued  for  several 
days,  becoming  more  severe,  notwithstanding  that  by  direction  of 
Dr.  Hilborne  West,  under  whose  charge  the  man  was,  and  with 
whom  I  saw  him,  six  ounces  of  blood  were  drawn  from  near  the 
affected  part.  On  the  fourth  day  of  the  disorder  the  patient 
was  assailed  with  excruciating  pain  along  the  course  of  the  ureter, 
attended  with  the  voiding,  at  short  intervals,  of  a  high-colored 
urine.  The  attack  lasted  from  six  o'clock  in  the  evening  until 
five  o'clock  the  next  morning,  leaving  the  patient  much  exhausted  ; 


*  Clinical  Lectures,  Lect.  II.,  on  Diseases  of  the  Urinary  Organs. 

43 


674  MEDICAL    DIAGNOSIS. 

the  only  relief  throughout  its  duration  being  obtained  from  the 
inhalation  of  chloroform.  At  six  o'clock  that  evening  another 
seizure,  of  equal  violence,  set  in  ;  and,  after  the  lapse  of  twenty- 
four  hours,  again  another.  Seeing  the  recurrence  of  the  parox- 
ysms at  about  the  same  time  of  each  day,  and  learning  from  the 
patient  that  a  few  months  before  he  had  had  a  remittent  fever, 
which  had  left  behind  an  irregular  intermittent,  we  resolved  upon 
the  administration  of  large  doses  of  sulphate  of  quinia  in  the 
interval  between  the  paroxysms.  The  seizure  did  not  take  place 
that  night;  but,  the  remedy  being  a  day  or  two  afterward  sus- 
pended, the  fourth  night  was  again  a  night  of  anguish.  The 
antiperiodic  was  resumed,  and  continued,  in  lessened  doses,  for 
three  weeks.  The  patient  remained  under  Dr.  West's  observa- 
tion for  about  six  weeks  after  the  last  attack,  gradually  recovering 
his  health  and  spirits.  When  he  was  lost  sight  of,  there  was  still 
a  dull  pain  in  the  left  lumbar  region,  with  inability  to  stand  erect; 
but  no  return  of  the  excruciating  intermittent  pains. 

In  a  case  of  this  kind  it  is  evident  that  nothing  but  a  knowl- 
edge of  the  history  of  the  patient,  and  the  noting  of  the  regularly 
recurring  onsets  of  the  pain,  could  have  led  to  a  correct  apprecia- 
tion of  its  cause.  We  sometimes  meet  with  a  so-called  neuralgia 
of  the  bladder,  of  similar  origin,  and  having  much  the  same 
symptoms,  except  that  the  distressing  pain  is  referred  to  the 
bladder.     As  in  the  case  just  detailed,  the  attacks  occur  at  night. 

These  remarks  are  all  based  on  the  assumption  that  the  renal 
pain  is  very  severe  and  paroxysmal  in  its  character.  Let  us  now 
briefly  inquire  into  the  significance  of  a  steady  and  less  acute  pain, 
premising  that  we  have  excluded  from  consideration  abdominal 
aneurism,  affections  of  the  muscles  of  the  back,  of  the  spine, 
and  of  the  tissues  surrounding  the  kidney,  in  which  diagnosis,  of 
course,  we  are  materially  assisted  by  an  examination  of  the  urine. 

We  meet  with  persistent  pain  referable  to  the  kidney  itself,  in 
inflammation  of  the  organ,  especially  in  that  variety  of  inflamma- 
tion affecting  the  infundibula  and  pelvis,  termed  pyelitis.  We 
also  encounter  it  in  malignant  disease  of  the  kidney;  sometimes, 
although  it  is  not  then  of  long  duration,  from  the  irritation  of 
concentrated  and  highly  acid  urine;  much  more  generally  from 
the  presence  of  a  stone  lodged  in  the  kidney.  The  pain  in  the 
latter  complaint  often  extends  along  the  course  of  the  ureter  to 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    675 

the  testicle,  which  is  retracted  and  swollen.  Not  unfrequently 
there  is  also  tenderness  on  pressure  over  the  affected  kidney,  and 
the  pain  is  greatly  increased  by  active  exercise;  and  it  is  not 
uncommon  to  find,  associated  with  these  exacerbations  of  pain, 
nausea  and  vomiting,  and  the  appearance  of  blood  in  the  urine. 

There  is  yet  another  point  in  the  diagnosis  of  the  passage  of 
calculi  which  we  must  not  overlook,  namely,  that  the  pain  may 
be  referred  to  other  parts  than  to  the  region  of  the  kidney  and  the 
course  of  the  ureter.  It  may  be  felt  near  or  at  the  sacrum,  and 
not  merely  on  one  side;  it  may  extend  to  the  bladder  and  become 
associated  with  a  painful  spasm  of  this  viscus  and  with  the  void- 
ing of  urine  drop  by  drop;  or  to  the  testicle,  which  becomes  sen- 
sitive and  swells;  or  to  the  thigh,  which  feels  numb;  or  it  may 
be  referred  to  the  right  hypochondrium  and  extend  downward, 
but  not  be  perceived  in  the  loin.  Under  the  latter  circumstances 
there  may  be,  with  pain  of  great  intensity,  coexisting  distention  of 
the  colon,  vomiting,  and  constipated  bowels,  and  the  symptoms  so 
closely  resemble  those  of  the  passage  of  a  biliary  calculus  that,  as 
we  learn  from  a  case  recorded  by  Owen  Rees,*  nothing  but  the 
detection  of  blood  in  the  urine  prevents  error.  Again,  as  hap- 
pened in  two  cases  which  came  under  my  notice,  the  pain  may  be 
referred  to  the  left  hypochondrium  or  along  the  course  of  the 
colon,  may  be  associated  with  soreness  to  the  touch  and  with  digest- 
ive disorders,  and  may  closely  simulate  an  organic  lesion  of  the 
stomach  or  intestine.  Nothing  but  careful  and  repeated  exami- 
nations of  the  urine,  and  observing  the  irregular  and  whimsical 
course  the  supposed  intestinal  malady  pursues,  will  enable  us  to 
arrive  at  a  knowledge  of  the  truth. 

Nor  must  we  be  unmindful  that  a  calculus  may  be  months  in 
passing,  and  that  as  it  changes  its  position  the  seat  of  the  pain 
changes.  I  had  a  case  of  the  kind  under  my  charge  in  a  lady 
about  fifty  years  of  age.  She  suffered  for  weeks  at  a  time  from 
excruciating  pains,  beginning  in  the  left  kidney,  then  felt  some- 
what below  it,  and  finally  localized  in  the  neighborhood  of  the 
left  ovary.  She  was  occasionally  free  from  pain  for  five  or  six 
days.  But  it  was  only  after  fully  nine  months  of  recurring 
suffering  that  the  passage  of  a  calculus  the  size  of  a  plum-stone, 

*  Guy's  Hospital  Keports,  3d  Series,  vol.  x. 


676  MEDICAL    DIAGNOSIS. 

followed  by  a  discharge  of  large  amounts  of  a  gritty  substance 
and  a  soapy-looking  urine,  removed  her  distress.  The  stone 
consisted  of  urates. 

The  symptoms  of  renal  calculus  may,  after  having  existed  for 
a  longer  or  shorter  time,  entirely  cease,  owing  either  to  the  calculus 
becoming  encysted  and  thus  remaining  innocuous,  or  to  its  obstruct- 
ing the  ureter,  causing  retention  of  the  urine,  and,  by  pressure, 
producing  gradual  atrophy  of  the  cortical  and  tubular  structures, 
the  kidney  being  finally  converted  into  a  mere  bag. 

In  concluding  the  consideration  of  this  subject,  it  will  be  useful 
to  group  together  the  symptoms  by  which  we  may  infer  the  exist- 
ence of  a  calculus  in  the  kidney.  They  are  :  frequent  micturition, 
often  attended  with  pain  at  the  end  of  the  penis;  pain  in  the  loin, 
with  or  without  accompanying  soreness,  occasionally  passing  sud- 
denly into  a  violent  paroxysm,  with  a  tendency  to  shoot  along  the 
course  of  the  ureter  to  the  testicle  and  the  hip  of  the  aching  side  ; 
and  in  some  cases  the  discharge  of  pus  due  to  coincident  pyelitis. 
These  symptoms  become  very  positive  evidence  if  the  blood-ex- 
tractives be  present  in  the  patient's  urine,  or  if  this,  when  exam- 
ined microscopically,  be  found  to  contain  blood  corpuscles;  or  if 
we  know  that  attacks  of  hematuria  have  previously  happened, 
and  that  gravel  or  small  urinary  concretions  have  at  any  time  been 
discharged.  But  all  of  these  indications  are  far  from  being  always 
present.  Any  one  of  them,  or  several  of  them,  may  be  absent. 
The  renal  stones  may  be  so  large  that  they  cannot  leave  the  kid- 
ney;  we  may  have  nothing  but  the  symptoms  of  a  pyelitis,  which 
we  may  rightly  or  wrongly  suspect  to  be  calculous,  and  even  these 
symptoms  may  be  wanting.  To  determine  whether  both  kidneys 
are  implicated  in  the  calculous  disease,  we  must  examine  the  urine 
during  the  passage  of  a  renal  calculus.  If  the  urine  be  perfectly 
healthy,  when  previously  it  has  been  abnormal,  we  conclude  that 
it  comes  from  a  healthy  kidney,  and  that  the  secretion  from  the 
diseased  one  is  temporarily  blocked  up. 

Diseases  marked  by  an  Albuminous  Condition  of  the  Urine, 
associated  with  more  or  less  Dropsy, 

Since  the  great  discovery  of  Bright,  that  dropsy  is  frequently 
dependent  on  disease  of  the  kidney,  revealing  its  existence  by 


THE  URINE  AND  DISEASES  OF  THE  URINARY   ORGANS.    677 

the  occurrence  of  albumen  in  the  urine,  a  host  of  laborers  have 
endeavored  to  enlarge  the  edifice  he  both  planned  and  erected ; 
but  thus  far  the  results  of  their  work  have  not  materially  changed 
the  original  fabric.  Certain  it  is  that,  beyond  the  researches  on 
the  minute  character  of  the  urine, — researches  which,  by  detect- 
ing the  tube-casts,  have  added  to  our  knowledge  in  a  way  not  to 
be  over-estimated, — little  has  been  brought  forward  that,  in  a 
clinical  point  of  view,  has  altered  the  structure  reared  by  the 
celebrated  physician.  The  work  progressing  aims  mainly  at 
proving  that  the  disease  which  bears  Bright's  name  consists  of  a 
group  of  maladies  having  the  common  feature  of  a  more  or  less 
albuminous  state  of  the  urine.  Now,  I  believe  that  this  view  will 
ultimately  be  everywhere  accepted.  But,  as  some  of  the  distinc- 
tions proposed  are  neither  so  constant  nor  so  undoubted  as  to  be 
made  the  groundwork  of  a  practical  separation,  I  shall,  in  this 
sketch,  prefer  to  consider  the  disorder  in  the  main  as  it  is  seen 
separated  by  broadly-drawn  lines  into  an  acute  and  a  chronic  form, 
endeavoring  to  incorporate  such  recently  acquired  facts  as  have  a 
readily  discerned  and  special  diagnostic  bearing. 

Acute  Bright's  Disease. — In  this  form  of  the  affection  the 
symptoms  are  of  an  acute  character.  Especially  so  is  the  dropsy, 
which  is  quickly  developed  and  soon  becomes  the  most  marked 
token  of  the  malady.  The  history  of  a  large  number  of  cases  is 
as  follows.  After  exposure  to  wet  or  cold,  a  fever  sets  in,  accom- 
panied by  nausea,  and  by  a  dull  pain  in  the  region  of  both  kid- 
neys, extending  along  the  course  of  the  ureters.  The  eyelids  and 
face  become  puffy  and  swollen,  and  soon  a  general  cedematous 
condition  of  the  skin  is  observable,  showing  itself  very  plainly  in 
the  extremities,  scrotum,  and  abdominal  parietes.  Subsequently 
dropsical  effusions  frequently  take  place  into  the  interior  cavities. 

A  similar  group  of  symptoms  is  apt  to  be  noticed  in  the  acute 
Bright's  disease  which  so  constantly  attends  scarlatina,  except 
that,  following  as  it  does  an  exhaustive  disease,  there  are  from 
the  onset  much  greater  pallor  and  general  debility. 

The  urine  in  both  these  forms  of  the  acute  malady  is  of  high 
specific  gravity,  and  dingy  from  its  admixture  with  blood.  There 
is  a  frequent  desire  to  void  it,  although  the  whole  quantity  passed 
is  rather  below  the  natural  average.  The  urine  contains  a  large 
amount  of  albumen ;  a  microscopical  examination  brings  to  light 


678 


MEDICAL    DIAGNOSIS. 


cast?,  lined  here  and  there  with  blood  corpuscles.  As  the  malady 
progresses,  these  "  blood-casts"  disappear,  and  we  find  the  eoagulable 
material  which  has  been  effused  into  the  tubes  coated  with  epithe- 
lium, which  may  be  normal  or  slightly  fatty,  and  with  free  nuclei; 
or  we  observe  it  to  be  slightly  granular,  or  quite  homogeneous; 
or  Ave  may  discern  pus  globules  taking  the  place  of  the  epithelial 
cells.  Furthermore,  crystals  of  uric  acid,  of  urates,  even  of  oxa- 
lates, and  a  considerable  amount  of  renal  epithelium,  are  objects 
often  seen  in  the  sediment.  The  normal  constituents  of  the  urine 
are  considerably  changed.  The  chlorides  may  have  disappeared 
altogether;  the  phosphates  are  diminished;  the  uric  acid  and  the 
pigments  are  increased.  The  amount  of  urea  fluctuates  much  :  it 
may  be  either  augmented  or  diminished. 


Fig.  46. 


Epithelial  casts  and  epithelial  cells  from  the  kidneys  found  in  a  case  of  acute 
Bright's  disease  (acute  desquamative  nephritis) ;  magnified  about  4G0  diameters. 

The  constitutional  disturbance  is  not,  as  a  rule,  extreme ;  the 
pulse,  however,  may  be  quick,  tense,  and  full.  The  skin  is 
generally  harsh  and  dry;  nausea  and  vomiting  are  of  common 
occurrence. 

The  urgent  symptoms  last  ordinarily  for  several  weeks.  When 
recovery  is  about  to  take  place,  they  abate ;  the  skin  becomes 
moist,  the  pulse  is  no  longer  accelerated,  and  hand  in  hand  with 
a  diminution  of  the  dropsy  the  quantity  of  the  urine  largely 
increases.  But  this,  although  fortunately  the  common,  is  not  the 
invariable  issue.     The  disease  may  gradually  lapse  into  a  chronic 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    679 

form.  Or,  as  sometimes  happens,  the  patient's  condition  decidedly 
ameliorates:  he  leaves  his  room,  as  he  thinks,  well,  yet  with  a 
certain  amount  of  albumen  in  his  urine ;  and  often  then  he  remains 
to  all  appearances  in  good  health,  until  after  a  fresh  exposure  the 
albumen  increases  in  the  urine,  and  the  dropsy  and  most  of  the 
acute  symptoms  return. 

Whatever  the  attending  circumstances,  the  risk  to  life,  when 
an  attack  has  been  at  all  prolonged,  is  greatly  increased  by  the 
supervention  of  local  inflammations, — as  of  the  pleura,  lungs, 
peritoneum,  or  pericardium  ;  or  by  the  sudden  effusion  of  fluid 
into  the  pulmonary  structure ;  or  by  the  retention  of  urea  in  the 
blood  and  consequent  ursemic  intoxication.  If  from  any  of  these 
complications  death  take  place,  the  kidneys  are  found  to  be  en- 
larged and  somewhat  irregularly  congested.  The  medullary  cones 
are  of  dark  color;  their  bodies  are  compressed,  while  their  bases 
expand  into  the  swollen  cortical  substance.  The  surface  of  the 
organ  is  smooth,  and  the  investing  capsule  is  easily  detached. 

The  recognition  of  the  disease  is  readily  effected.  The  puffy, 
pale  face ;  the  general  dropsy ;  the  albumen  in  the  urine,  associated 
with  tube-casts,  form  a  combination  of  signs  so  remarkable  that 
it  is  difficult  to  mistake  their  meaning.  Many  of  the  same  phe- 
nomena are  encountered,  although  not  always  to  the  same  degree, 
in  the  chronic  form  of  the  malady :  what  is  therefore  about  to  be 
said  of  the  differential  diagnosis  of  the  acute  complaint  may  be 
in  the  main  applied  with  almost  equal  correctness  to  the  chronic 
ailment. 

The  chief  disorders  with  which  acute  Bright's  disease  is  apt  to 
be  confounded  are : 

Acute  Nephritis; 

Suppurative  Nephritis  ; 

hematuria  and  purulent  urine ; 

Simple  Albuminuria  ; 

Pulmonary  (Edema ; 

Pleurisy  and  Pericarditis; 

Dropsy  ; 

Coma;  Convulsions. 

Acute  Nephritis. — This  differs  from  acute  Bright's  disease  by 
its  affecting  generally  only  one  kidney,  by  the  much  greater  pain 
and  tenderness  in  the  lumbar  region,  by  the  retraction  of  the 


680  MEDICAL    DIAGNOSIS. 

testicle,  and  by  the  higher  degree  of  febrile  excitement.  Then, 
too,  the  deeply-colored  urine  which  is  voided  contains  little  or  no 
albumen. 

Suppurative  Nephritis. — In  rare  cases  the  suppurative  process 
may  coexist  with  Bright's  disease.  But,  on  the  whole,  the  two 
disorders  are  distinct,  and  may  be  readily  discriminated.  Suppu- 
rative nephritis  occurs  from  external  violence,  from  exposure  to 
cold  and  wet,  from  a  morbid  condition  of  the  blood,  as  in  pysemia, 
from  metastasis  through  embolism,  or  from  the  impaction  of  a 
renal  calculus,  and  may  lead,  like  Bright's  disease,  to  uremic 
symptoms.  But  it  usually  attacks  only  one  kidney,  occasions 
much  local  pain,  is  frequently  attended  with  a  fever  more  or  less 
remittent  or  intermittent  in  its  character,  and  at  times  with  a  well- 
defined  swelling,  which  may  be  felt  in  the  lumbar  region  and 
extending  far  downward.  Now,  all  this  is  very  different  from 
Bright's  disease,  which  always  aifects  both  kidneys,  and  in  which 
no  enlargement  of  the  organs  can  be  perceived  through  the  ab- 
dominal walls.  Then,  we  detect  blood  and  pus  in  the  urine  of 
cases  of  suppurative  nephritis,  and  any  casts  that  are  found  are 
seen  to  be  covered  with  pus  corpuscles. 

Ucematuria  and  Purulent  Urine. — In  both  these  complaints,  if 
we  can  speak  of  them  as  such,  and  otherwise  than  as  symptoms, 
there  is  albumen  in  the  urine ;  and,  on  the  other  hand,  traces  of 
blood  and  pus  may  be  present  in  the  urine  of  Bright's  disease. 
But  the  quantity  of  albumen  met  with  in  hematuria  or  in  puru- 
lent urine  is  small ;  in  fact,  it  is  in  exact  proportion  to  the  amount 
of  pus  or  blood  the  excreted  fluid  contains ;  whereas,  on  the  con- 
trary, if  the  secretion  from  a  Bright's  kidney  be  mixed  with  pus 
or  blood,  the  amount  of  albumen  is  very  large. 

Simple  Albuminuria. — By  this  is  meant  an  albuminous  urine 
unconnected  with  any  marked  structural  lesion,  unless  congestion, 
— such  an  albuminuria  as  is  sometimes  observed  as  a  transient  phe- 
nomenon in  the  course  of  several  diseases;  as,  for  instance,  in  the 
exanthemata,  in  typhus,  in  cholera,  in  hectic  fever,  in  chronic  con- 
gestion of  the  liver,  or  as  a  consequence  of  surgical  diseases  and 
operations.*     An  albuminuria  of  similar  kind  is  also  met  with 


*  Henry  Lee,   Lectures  on   Practical   Pathology  and   Surgery,  3d  edit., 
London,  1870,  vol.  ii.  p.  380. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    681 

when  the  kidneys  become  congested  from  interference  with  the 
circulation,  as  in  disease  of  the  heart,  or  from  the  pressure  of  a 
gravid  womb.  Albumen  in  the  urine  may  also  be  encountered  in 
erysipelas,  in  diphtheria,  in  pneumonia,  in  acute  rheumatism  and 
in  gout,*  consecutively  to  a  blister  or  large  mustard-plaster,  or  to 
the  use  of  salicylic  acid,  or  of  turpentine  or  carbolic  acid,  or  after 
partaking  plentifully  and  exclusively  of  albuminous  food.f  But 
in  all  these  conditions  the  quantity  found  is  small  and  transitory, 
very  unlike  what  it  is  in  the  persistent  albuminuria  of  Bright's 
disease,  and  the  urine  is  usually  dense  and  high-colored.  Then 
the  constitutional  symptoms  in  the  morbid  states  referred  to  are  so 
dissimilar  to  those  of  Bright's  disease  that  they  become  a  safe- 
guard against  error. 

Yet  the  most  valuable  aid  in  forming  a  judgment  is  derived 
from  a  microscopical  investigation  of  the  urinary  sediment.  In 
simple  albuminuria  there  is  no  exudation;  hence  no  tube-casts  can 
be  detected  in  the  urine.  This,  at  least,  represents  the  general 
truth.  Still,  we  must  admit  that  repeated  and  searching  exami- 
nations may  detect  occasionally  a  few.  Yet  their  inconstancy, 
their  character,  the  small  amount  of  albumen  they  are  commonly 
associated  with,  are  of  significance;  and  the  general  nature  of 
the  symptoms  again  helps  to  explain  their  meaning.  Then,  too, 
the  kidney  may  be  really,  in  several  of  the  morbid  states  under 
discussion,  in  the  same  condition  as  in  the  earlier  stages  of  acute 
Bright's  disease;  but  for  the  most  part  it  is  simply  in  a  state  of 
hyperemia,  either  active  or  more  generally  passive  from  con- 
gestion, and  it  is  unlike  the  swollen  organ  and  the  fully-developed 
malady  with  its  marked  clinical  features  which  we  have  above 
described. 

Pulmonary  CEdema. — Bright's  disease  is  one  of  the  most  fre- 
quent causes  of  pulmonary  congestion  and  dropsical  effusion  into 
the  air-cells :  oppression  in  breathing,  inability  to  lie  in  the  re- 
cumbent position,  cough,  frothy  expectoration,  are  therefore 
common  among  the  symptoms  attending  the  renal  affection. 
And,  to  distinguish    this  oedema  from   that  produced  by  other 

*  Thudichum,  op.  cit. 

f  Hammond's  Physiological  Memoirs;  Simon's  Animal  Chemistry.  See 
also  a  very  good  summary  of  the  conditions  in  which  albuminuria  may 
appear,  by  Calvin  Ellis,  Bosfon  Medical  and  Surgical  Journal,  1880. 


682  MEDICAL    DIAGNOSIS. 

morbid  states,  \vc  have  only  to  examine  the  urine  carefully, — a 
matter,  indeed,  which  ought  not  to  be  neglected  in  any  case  of 
oedema  of  the  lungs. 

Pericarditis  and  Pleuritis. — The  tendency  to  internal  inflamma- 
tions, especially  to  those  of  the  serous  membranes,  is  a  remarkable 
peculiarity  of  Bright's  disease.  We  may  discriminate  pericarditis 
or  pleuritis  complicating  the  malady,  from  either  of  these  affec- 
tions of  other  origin,  by  noting  the  far  greater  amount  of  dropsy 
than  is  ordinarily  found  in  these  disorders,  and  by  detecting 
albumen  and  tube-casts  in  the  urine  significant  of  the  exact  state 
of  the  kidney. 

Dropsy. — By  an  examination  of  the  urine,  too,  may  be  dis- 
tinguished the  dropsy  of  the  complaint  under  consideration  from 
that  produced  by  other  causes.  And,  independently  of  the  phys- 
ical properties  of  the  urine,  we  see  very  often  the  evidences  of 
the  true  nature  of  the  dropsy  in  its  beginning  with  swelling  of 
the  face  and  then  becoming  universal,  and  in  the  striking  and 
characteristic  physiognomy  which  it  has  a  share  in  developing. 
But  more  will  be  said  hereafter  on  these  points.  The  dropsy 
is  generally  looked  upon  as  due  to  the  kidneys  not  eliminating 
the  water,  and  the  subsequent  increase  of  blood-pressure  in  the 
capillaries  and  veins.  Moreover,  the  altered  condition  of  the 
blood  favors  transudation. 

Coma;  Convulsions. — A  dangerous  complication  of  Bright's  dis- 
ease manifests  itself  by  signs  of  great  derangement  of  the  nervous 
system,  prominent  among  which  are  drowsiness  and  convulsions. 
Now,  it  is  very  important  to  distinguish  the  cases  produced  by 
ursemic  poisoning  from  epileptiform  convulsions  and  kindred 
states  in  which  there  is  no  appreciable  change  of  structure  in 
the  kidneys.     Let  us  see  how  they  differ. 

Uraemia,  or  ursemic  intoxication,  is  most  commonly  preceded 
by  a  diminution  in  the  urinary  secretion.  There  is  headache,  with 
indistinct  vision,  great  drowsiness,  and  vertiginous  sensations;  the 
pupils  are  sluggish  and  usually  dilated;  the  hearing  is  impaired; 
the  countenance  is  dusky ;  the  skin  is  cool,  with  short  exacerba- 
tions of  heat;  and  the  patient  suffers  from  constipation,  nausea,  and 
obstinate  vomiting.  Paralysis  of  sensation  may  be  observed  in  the 
extremities.  The  dulness  of  mind  is  apt  to  deepen  into  stupor 
or  coma,  or  convulsions  set  in  as  precursors  of  the  coma,  which 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    683 

terminates  in  death,  unless  the  urinary  secretion  be  freely  re- 
established. The  coma  may  at  one  time  be  so  profound  that  it  is 
impossible  to  arouse  the  patient,  whilst  at  another  time  he  rouses 
himself,  and  acts  with  considerable  intelligence.  The  convulsions 
generally  succeed  one  another  rapidly,  and  he  may  not  have  re- 
covered from  the  dulness  following  one  before  another  comes  on. 

In  some  cases  the  marked  phenomena  set  in  with  a  chill,  by 
which  the  eliminating  function  of  the  skin  is  suppressed;  in  other 
cases,  however,  there  is  no  such  obvious  beginning.  And  as  re- 
gards the  decided  lessening,  or  even  suppression,  of  the  urinary 
secretion,  though  this  is  the  rule,  it  is  not  constant.  I  wish  here 
particularly  to  call  attention  to  this  point;  for  I  have  known  many 
an  error  in  diagnosis  to  be  committed,  and  the  symptoms  of  ursemia 
many  a  time  to  receive  an  erroneous  interpretation,  from  sup- 
posing that  this  state  could  not  exist,  as  the  quantity  of  urine 
passed  was  about  normal.  We  must  test  for  urea  and  the  other 
urinary  ingredients,  which  may  be  profoundly  changed  in  amount, 
notwithstanding  the  seemingly  healthy  aspect  of  the  secretion,  and 
notwithstanding,  too,  that  it  may  be  found  free  from  albumen. 

Cases  of  ursemic  coma  differ  from  ordinary  comatose  conditions, 
as  witnessed  in  apoplexy,  in  fevers  of  a  low  type,  or  following 
narcotic  poisoning,  by  the  dissimilar  symptoms  ushering  them  in. 
The  coma  is  much  more  suddenly  developed  than  that  in  fevers ; 
far  less  suddenly  than  that  of  apoplexy  or  narcotic  poisoning.* 
Then,  the  stertorous  respiration,  to  adopt  the  observation  of  Addi- 
soiijf  is  peculiar :  the  loud  sounds  of  the  expired  air  are  of  much 
higher  key,  not  like  the  low,  guttural  tones  of  apoplexy.  Fur- 
thermore, we  have  in  the  general  dropsy  a  clue  to  the  nature  of 
the  case ;  but  of  course  the  most  certain  light  is  thrown  on  it  by 
the  analysis  of  the  urine.  And  often,  indeed,  until  this  has  been 
effected,  no  positive  judgment  can  be  given;  for  the  dropsy  may 
be  so  very  slight  as  to  escape  observation,  and  the  other  signs  be 
ill  defined. 

The  same  remarks  apply  to  the  delirium  or  to  the  epileptiform 

*  There  may,  however,  be  exceptions  to  this  rule,  as  in  a  curious  instance 
reported  by  Moore  in  the  London  Medical  Gazette,  1845,  in  which  a  person 
became  comatose  after  taking  laudanum,  yet  his  death  was  found  to  have 
been  caused  by  contracted  kidneys. 

f  Guy's  Hospital  Eeports,  1859. 


684  MEDICAL    DIAGNOSIS. 

convulsions  of  unemia.  And  here  the  difficulty  in  diagnosis  is 
increased  by  the  first  seizure  often  happening  unexpectedly ;  so 
much,  in  truth,  increased,  that,  unless  we  are  aware  of  the  his- 
tory of  our  patient  and  have  previously  examined  his  urine,  the 
true  explanation  of  the  symptoms  is  not  to  be  reached.  Urcemic 
delirium  is  rare,  but  I  have  met  with  it  under  circumstances  in 
which  nothing  preceded  it  to  indicate  its  nature,  and  in  which  it 
was  very  marked.*  Cases  of  acute  urcemic  mania  may  also  origi- 
nate thus  suddenly.  Cases  of  urcemic  convulsions  may  occur  in 
pregnant  women;  in  them,  however,  the  tendency  to  disorder  of 
the  kidney  is  so  great  that  we  are  rarely  in  error  in  concluding 
the  convulsions  to  be  of  uraernie  origin.  We  must,  however, 
here,  as  in  all  convulsions,  be  certain  that  we  do  not  mistake 
effect  for  cause.  A  slight  amount  of  albumen  may  follow  violent 
convulsions  in  epileptic  seizures.  The  temperature  in  urcemic 
convulsions  is  said  by  Bourneville  to  be  low;  but  this  is  denied 
by  a  recent  observer,  who  notes  it  as  considerably  elevated. f 

The  cause  of  uraemia  is  still  unsettled  :  an  alteration  of  the 
urinary  secretion  and  a  contamination  of  the  blood  by  retained 
urinary  ingredients  we  may  fairly  assume  as  always  happening. 
The  fact  that  the  grave  phenomena  are  thought  by  some  to  be 
due  to  the  urea,  by  others  to  its  decomposition  into  carbonate  of 
ammonia,  has  been  already  alluded  to.  See  has  suggested  that 
they  may,  in  different  cases,  be  owing  to  either,  and  has  indicated 
the  features  by  which  uraemia  may  be  distinguished  from  ammo- 
nicemia.  In  the  former  there  is  no  fever;  a  clean  tongue;  a 
smooth,  elastic  skin ;  a  disordered  respiration,  but  not  a  dis- 
ordered circulation ;  convulsions  and  coma.  In  the  latter  we 
always  find  mucus  or  pus  in  the  urine,  and  an  affection  in  conse- 
quence of  which  the  urine  is  retained  somewhere  in  the  urinary 
passages;  there  are  chills,  followed  by  burning  heat  of  surface; 
a  dry,  grayish  skin,  exhaling,  like  the  breath,  an  ammoniacal 
odor;  a  dry  tongue;  emaciation;  rarely  vomiting;  the  respiration 
is  free,  the  circulation  deranged ;  headache  occurs,  but  the  intelli- 
gence remains  good. 

Chronic  Bright's  Disease. — An  acute  attack  of  Bright's 

*  Case  at  the  Pennsylvania  Hospital,  April,  1865. 
f  Bartels,  in  Ziemssen's  Cyclopaedia. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    685 

disease  may  become  prolonged,  and  gradually  pass  into  a  con- 
firmed malady,  or  the  complaint  may  come  on  insidiously  from 
the  onset  and  develop  itself  very  slowly.  In  either  case  we  have 
a  dangerous  chronic  affection  established. 

The  transition  from  the  acute  to  the  chronic  disease  is  indicated 
by  the  disappearance  of  blood  from  the  urine,  by  its  lessened  spe- 
cific gravity,  and  by  the  smaller  amount  of  albumen  it  contains; 
and  not  uncommonly  by  a  temporary  diminution  of  the  anasarca 
and  an  increase  in  the  quantity  of.  urine  voided.  Ringer*  states 
that  a  sign  more  trustworthy  than  any  of  those  mentioned  is 
afforded  by  the  temperature  of  the  body.  When  the  acute  stage 
ceases,  the  thermometer  indicates  a  normal,  not  an  increased,  tem- 
perature. 

When  the  disease  runs  a  more  or  less  chronic  course  from  the 
beginning,  its  initiatory  steps  are  very  obscure.  We  generally 
find  such  cases  in  persons  who  are  poorly  fed  and  half  clad,  who 
live  in  damp,  ill-ventilated  houses,  who  are  intemperate,  or  who 
have  been  subject  to  great  grief  or  worry,  or  who  are  saturated 
with  malaria,  or  whose  constitutions  are  ruined  by  syphilis  or  by 
scrofula.  The  first  symptoms  they  notice  may  be  frequent  desire 
to  urinate;  swelling  of  the  extremities  or  of  the  face;  increasing 
pallor  and  general  debility;  and  headache,  especially  occipital 
headache. 

They  seek  medical  advice,  and  an  examination  of  the  urine 
reveals  at  once  the  cause  of  their  protracted  indisposition.  Yet 
the  renal  disease  may  lead  suddenly  to  a  fatal  termination  without 
the  patient  having  previously  experienced  any  manifest  or  urgent 
signs  of  ill  health.  And  even  after  the  malady  has  been  fully 
recognized  it  is  very  difficult  to  predict  its  course.  In  truth, 
different  cases  present  different  symptoms.  We  meet  in  many 
with  the  same  phenomena  as  those  encountered  in  the  acute  variety, 
and  life  is  threatened  by  the  same  dangerous  complications;  but 
in  others  the  signs  are  dissimilar, — the  dropsy,  for  instance,  is  very 
sligrlit  or  is  wliollv  wanting,  or  the  amount  of  albumen  is  small. 
The  only  constant  and  characteristic  manifestations  are  the  pro- 
found and  increasing  aneemia,  and  the  presence  of  albumen  and 
tube-casts  in  the  urine. 

*  Lancet,  Nov.  1865. 


Q86  MEDICAL    DIAGNOSIS. 

Generally,  too,  the  fluid  is  of  low  specific  gravity.  Now,  the 
altered  specific  gravity  can  only  be  dependent  upon  a  diminution 
of  the  urinary  solids.  The  urea  is  lessened,  and  so  are,  as  a  rule, 
the  uric  acid,  the  pigment,  and  the  salts.  Commonly,  also,  the 
urine  is  not  so  abundant  as  in  health,  and  its  reaction  is  less  acid. 

The  albumen  is  very  variable  in  amount;  its  quantity  may,  in- 
deed, fluctuate  much  in  the  same  patient,  and  even  change  from 
day  to  day.  It  is  persistent;  yet  it  may,  in  some  eases,  disappear 
for  a  short  time. 

The  tube-casts,  too,  are  not  uniform, — not  nearly  so  much  so  as 
in  the  acute  variety  of  the  affection.  We  meet  with  casts  almost 
or  quite  homogeneous,  and  small  or  large;  with  casts  besprinkled 
with  shrivelled  degenerating  epithelium;  with  casts  covered  with 
granules  or  with  oil-drops.  In  the  progress  of  a  particular  case, 
nearly  all  of  these  forms  may  be  encountered,  although,  as  we 
shall  hereafter  see,  the  preponderance  of  any  one  of  them  affords 
an  indication  as  to  the  exact  state  of  the  kidneys.  There  is  only 
one  kind  we  do  not  find  in  the  chronic  disorder:  the  one  covered 
with  well-developed  epithelial  cells  or  blood  corpuscles.  The 
apparent  absence  of  casts  from  albuminous  urine  is  not  absolute 
proof  of  the  non-existence  of  renal  degeneration.  In  some  cases 
their  absence  is  only  temporary,  while  in  others  they  are  small 
and  few  in  number  and  easily  escape  detection,  even  after  most 
careful  search. 

Other  minute  features,  too,  it  has  been  sought  to  turn  to  ad- 
vantage. Thus,  it  is  suggested  by  J.  G.  Richardson*  that  we  may 
derive  additional  aid  in  diagnosticating  the  form  and  stage  of  the 
renal  affection  by  a  careful  study  of  the  white  elements  of  the 
blood,  found  in  varying  proportion  in  the  urine. 

From  these  remarks,  it  is  obvious  that  a  great  diversity  of  phe- 
nomena is  witnessed  in  chronic  Bright's  disease:  so  great,  in  truth, 
is  this  diversity  that  the  opinion  is  fast  being  adopted  that  there 
are  several  distinct  pathological  affections  embraced  under  the  one 
term,  and  attempts  have  of  late  years  been  made  to  define  accu- 
rately the  train  of  symptoms  significant  of  each.  But,  notwith- 
standing that  a  means  of  separation  is  also  afforded  by  the  very 
varied  aspect  of  the  organ, — enlarged  or  fatty  in  some  instances, 

*  American  Journal  of  the  Medical  Sciences,  Jan.  1870. 


THE  EEIXE  AXD  DISEASES  OF  THE  UEIXARY  ORGAXS.    687 

diminished  or  waxy  in  others, — it  is  confusing  to  arrange  the 
symptoms  solely  with  reference  to  the  morbid  anatomy  of  the 
kidney;  and  it  is  best  to  consider  the  differential  diagnosis  of 
chronic  Bright's  disease  continuously,  pointing  out,  after  having 
done  so,  the  clinical  features  which  are  supposed  to  be  indicative 
of  the  various  forms  of  the  malady. 

Leaving  out  of  consideration  those  affections  for  which  both 
the  acute  and  the  chronic  disease  may  be  mistaken,  and  which 
have  been  already  discussed,  chronic  Bright's  disease  may  be  con- 
founded with — 

Anemia  ; 

Xeuealgia  ; 

Cheoxic  Rheumatism  ; 

Cheoxic  Bronchitis; 

Asthma  ; 

Cardiac  Dropsy; 

Gasteo-ixtestixal  Disorders; 

caxcee ;  tubeectjlosis  ;  cysts  op  kldxey. 

Anaemia. — There  are  few  diseases  which  alter  the  blood  so  com- 
pletely as  does  chronic  Bright's  disease.  The  blood  corpuscles  go 
on  steadily  diminishing,  while  the  fibrin  holds  its  own,  and  the 
quantity  of  albumen  fluctuates  considerably,  being  ordinarily  much 
reduced.  Besides  these  changes,  the  blood  often  retains  its  effete 
ingredients,  since  the  kidneys  are  incapable  of  performing  their 
function.  The  alteration  and  gradual  impoverishment  of  the 
blood  make  themselves  manifest  by  the  increasing  debility,  and 
by  the  pallor  and  waxy  look  of  the  countenance. 

We  may  discriminate  this  anasmic  or  chlorotic  condition  from 
that  unconnected  with  renal  disease  by  the  existence  of  albumen 
and  tube-casts  in  the  urine,  and  often  also  by  the  prominence  of 
the  dropsical  symptoms.  But  it  is  essential  to  know  that  some 
of  the  phenomena — certainly  albuminous  urine  and  dropsy — may 
attend  the  anaemia  following  profuse  or  frequently-repeated  hem- 
orrhages, without  the  structure  of  the  kidneys  having  been  im- 
paired. It  is  difficult  to  distinguish  these  cases  from  true  Bright's 
disease,  except  by  taking  into  account  the  diminution  of  the  albu- 
men as  the  hemorrhagic  tendency  is  lost,  and  the  absence  of  the 
tube-casts.  The  dropsy,  unless  it  be  considerable,  can  hardly  be 
looked  upon  as  a  valuable  differential  index,  for  a  slight  or  moder- 


688  MEDICAL    DIAGNOSIS. 

ate  amount  of  dropsy,  or  even  none  at  all,  may  be  encountered  in 
either  morbid  state. 

The  ophthalmoscopic  appearances  presented  by  the  retina,  and 
described  in  a  previous  part  of  this  work,  afford  help  in  distin- 
guishing between  the  ansemia  of  Bright's  disease  and  that  pro- 
duced by  any  other  cause.  The  enlarged  tortuous  veins,  the 
swollen  papilla,  the  white  patches  upon  the  retina,  opposite  to  and 
around  the  optic  entrance,  the  hemorrhagic  effusions,  are  quite 
characteristic,  and  especially  belong  to  granular  degeneration  of 
the  kidney.  But  albuminuric  retinitis  is  not  limited  to  any  form 
of  Bright's  disease.  It  generally  happens  in  both  eyes,  and,  though 
in  the  chronic  variety  of  the  malady  it  may  greatly  improve,  it 
does  not  disappear.  The  sight  itself  deteriorates ;  and  we  have 
attacks  of  blindness,  urseraic  amaurosis,  which  come  on  suddenly 
and  pass  off  suddenly. 

Neuralgia. — As  this  is  not  infrequent  in  the  chronic  form  of 
Bright's  disease,  we  must  always,  in  obstinate  cases  of  neuralgia, 
examine  the  urine,  so  as  to  see  whether  or  not  a  renal  affection 
lie  at  the  root  of  the  painful  malady.  The  neuralgia  may  affect 
the  fifth  nerve,  or  other  nerves ;  sometimes  it  takes  more  the  form 
of  hemicrania,  and  it  is  often  associated  with  disordered  vision,  or 
with  impairment  of  other  special  senses;  or  it  may  coexist  with 
persistent  headache  or  with  strange  and  anomalous  nervous  symp- 
toms. Headache  from  Bright's  disease  may  also  be  present 
without  neuralgia;  it  may  be  of  the  nature  of  megrim,  and  occur 
in  paroxysms  attended  with  nausea  and  vomiting. 

Chronic  Rheumatism. — Frequently  patients  affected  with  chronic 
Bright's  disease  complain  of  muscular  pains.  The  pain  is  dull, 
not  increased  on  pressure ;  sometimes  shooting,  more  like  that 
ordinarily  called  neuralgic,  and  to  which  we  just  called  attention. 
The  pain  is  oftenest  met  with  in  those  instances  in  which  the 
dropsy  is  slight  or  wholly  wanting,  and  an  examination  of  the 
urine  is  then  the  only  means  of  determining  its  real  significance. 

Chronic  Bronchitis. — This  is  one  of  the  most  common  com- 
plications of  Bright's  disease, — so  common,  indeed,  that  Rayer 
observed  it  in  seven-eighths  of  his  patients,  and  Wilks*  states  it, 
from  an  extensive  analysis  of  cases,  to  have  been  more  universal 

*  Guy's  Hospital  Reports,  2d  Series,  vol.  viii. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    689 

than  any  other  single  symptom,  albuminous  urine  alone  excepted. 
It  is  hardly  necessary  to  add  that  the  last-mentioned  sign  is  the 
one  that  distinguishes  this  secondary  pulmonary  trouble  from  all 
other  forms  of  bronchial  disease. 

Asthma. — Whether  or  not  there  be  coexisting  bronchitis,  attacks 
of  shortness  of  breath,  like  paroxysms  of  asthma,  occur  as  the 
result  of  Bright's  disease.  This  renal  asthma  is  most  common  in 
the  chronic  contracted  kidney.  It  has  no  features  by  which  it 
can  be  recognized  from  ordinary  asthma,  except  that  I  do  not 
think  that  the  wheezing  and  the  rales  are  so  marked  or  that 
it  subsides  by  copious  expectoration.  It  resembles  indeed  more 
cardiac  asthma,  and  is  most  frequent  at  night. 

Cardiac  Dropsy. — A  chronic  disorder  of  the  kidney  is  often 
connected  with  disease  of  the  heart ;'  and,  knowing  the  frequent 
combination  of  an  organic  cardiac  malady  with  Bright's  disease, 
it  becomes  our  duty,  in  every  instance  of  dropsy  associated  with  a 
cardiac  affection,  to  examine  the  urinary  secretion  carefully,  for 
both  the  prognosis  and  treatment  are  influenced  by  the  result  of 
a  search  of  tin's  character. 

Let  us  suppose  that  in  cases  of  so-called  cardiac  dropsy  we  find 
albumen  in  the  urine:  is  this  a  proof  of  coexisting  Bright's 
disease?  ]So;  unless  the  amount  of  the  abnormal  ingredient 
be  considerable,  or  tube-casts  accompany  the  albuminuria.  Mere 
congestion  of  the  kidneys,  resulting  as  it  does  from  an  obstruction 
to  the  flow  of  the  venous  blood  along  the  vena  cava,  may  occasion 
albuminuria ;  but  the  presence  of  albumen  is  temporary,  and  its 
quantity  small.  A  large  amount,  persistent  and  conjoined  with 
tube-casts,  shows  that  changes  have  begun  in  the  renal  textures. 

Gastro-intestinal  Disorders. — These,  it  is  well  known,  are  among 
the  most  common  consequences  of  the  renal  malady.  They  mani- 
fest themselves  in  various  ways.  Some  patients  suffer  from  flatu- 
lency and  indigestion  ;  others  from  diarrhoea ;  others,  again,  from 
nausea  and  vomiting.  The  latter  symptoms  are  very  apt  to  occur 
when  urea  accumulates  in  the  blood  and  the  phenomena  of  ursernic 
intoxication  are  clearly  developed.  They  may  be,  however,  also 
met  with  at  any  period  of  the  disease  without  the  concurrence  of 
other  urgent  symptoms,  and  become  so  prominent  as  to  throw 
into  the  background  most  of  the  other  signs  of  the  renal  affection. 

To  cite  a  case  in  point :  an  assistant  nurse  in  the  medical  ward 

U 


690  MEDICAL    DIAGNOSIS. 

of  the  Philadelphia  Hospital  was  attacked  suddenly  with  nausea 
and  vomiting,  which  persisted  in  spite  of  the  remedies  employed, 
and  became  so  troublesome  that  the  man  had  to  desist  from  his 
occupation.  There  was  no  febrile  disturbance;  the  tongue  was 
clean;  the  epigastric  region  was  not  tender  to  the  touch.  Except  a 
slight  bronchitis,  there  were  no  apparent  signs  of  disease  in  any 
organ  in  the  body,  and  nothing  to  account  for  the  gastric  irrita- 
bility. A  close  inquiry  into  the  history  of  the  patient  revealed 
that  he  had  had  an  attack  of  dropsy  some  time  previously,  from 
which  he  had  recovered.  But  of  late  he  had  again  noticed  a 
swelling  of  the  feet;  and,  on  examination,  a  slight  oedematous 
condition  was  found  to  exist.  From  the  combination  of  these 
signs  I  drew  the  conclusion  that  a  chronic  renal  disease  lay  at  the 
bottom  of  the  gastric  disturbance ;  and  the  detection  of  albumen 
and  of  casts  in  the  urine  proved  the  opinion  to  be  correct. 

Cancer;  Tubercle;  Cysts  of  Kidney. — These  morbid  products 
affect  the  kidneys  but  rarely, — at  all  events,  rarely  in  a  form  so 
marked  as  to  give  rise  to  conspicuous  clinical  phenomena.  In  all 
of  them  there  may  be  albumen  present  in  the  urine,  but  it  is  gen- 
erallv  in  small  amounts,  and  mixed  with  some  ingredient  having 
a  more  specific  meaning.  Thus,  in  cancer  of  the  kidney  we  may 
find  blood  with  the  albumen ;  indeed,  hematuria  is  a  very  impor- 
tant symptom,  and  in  some  instances  we  discern  with  the  micro- 
scope cells  like  those  observed  in  any  cancerous  growth;  often  the 
hemorrhages  are  profuse  and  frequently  recurring,  are  preceded  by 
severe  pain,  and  we  may  detect  a  palpable  tumor  in  the  flank.  In 
cases  of  melanotic  cancer,  whether  it  have  its  seat  in  the  urinary 
apparatus  or  elsewhere,  Eiselt  and  Bolze*  have  noticed  that  the 
urine  on  standing  assumes  the  color  of  porter,  and  that  on  the 
addition  of  concentrated  nitric  acid  it  instantly  presents  the  same 
dark  color;  facts  which  they  regard  as  highly  diagnostic.  In 
children,  cancer  of  the  kidney  is  not  a  rare  disease,!  and  when  we 
can  exclude  as  the  cause  of  the  renal  tumor  cystic  degeneration 
and  hydronephrosis, — in  them  congenital  affections, — we  can  diag- 
nosticate the  case  with  some  certainty.  In  adults  the  diagnosis  is 
always  doubtful,  at  least  when  the  disease  is  primary.     A  rapid 

*  Prager  Vierteljahr.,  vols.  lix.  and  lxvi. 
f  Braidwood,  Liverpool  Reports.  1870. 


THE  URIXE  AND  DISEASES  OF  THE  URINARY  ORGANS.    691 

and  irregular  growth  of  the  renal  tumor,  severe  pain,  bloody  urine, 
and  cachexia  are  the  most  certain  signs. 

In  tubercle,  little  yellow  cheesy  masses  of  degenerated  tuber- 
cular matter  collect  as  a  sediment,  as  in  the  cases  referred  to  by 
Frerichs  in  his  work  on  Bright's  disease.  The  constant  presence 
of  this  sign  is,  however,  very  doubtful.  The  tubercular  matter  is 
derived  from  the  ureters  or  pelvis  of  the  kidneys.  The  deposit 
it  forms  in  the  urine  is  insoluble  in  acetic  acid ;  and  Vogel  de- 
scribes the  microscopical  characters  of  the  deposit,  as  irregular 
corpuscles  not  exhibiting,  when  treated  with  acetic  acid,  normal 
nuclei,  or  showing  only  small,  irregular  nucleoli,  and  an  ill-defined 
detritus,  with  fragments  of  cells  and  an  indistinct  and  finely- 
granular  mass,  with  which  crystals  of  cholesterin  are  sometimes 
mingled.  Pus  and  other  signs  of  chronic  pyelitis  are  also  pres- 
ent, and  there  is  no  other  assignable  cause  for  the  existence  of  the 
suppurative  disease  than  tubercle.  We  may  be  assisted  in  the 
diagnosis  by  finding  tubercles  in  other  organs.  Rayer  tells  us 
that  scrofulous  disease  of  the  vertebras  has  repeatedly  been  ob- 
served to  be  associated  with  tubercular  kidneys.  In  tubercle  of 
the  kidney,  extreme  pain,  occurring  in  paroxysms  like  those  of 
nephritic  colic,  is  a  very  important  sign.  This  pain,  as  I  have  had 
occasion  to  observe,  is  associated  with  frequent  micturition,  and 
is  temporarily  relieved  by  the  flow  of  water.  The  urine  is,  how- 
ever, scanty.  A  moderate  amount  of  hematuria  may  happen  ;  the 
patient  passes  at  times  little  fibrinous  shreds,  and  emaciates  steadily. 

Cheesy  inflammation  of  the  kidney  is  now  separated  by  many 
from  tubercle,  with  which  it  may  or  may  not,  it  is  taught,  coexist. 
The  nephrophthisis  is  met  with  oftener  in  men  than  in  women, 
and  the  caseous  inflammation  may  begin  in  the  mucous  membrane 
of  the  bladder,  or  in  the  prostate  and  extend  to  the  kidney.*  The 
urine  is  generally  acid,  and  small  cheesy  masses,  elastic  fibres,  and 
shreds  of  cast-off  connective  tissue  may  be  found.  A  renal  tumor 
can  rarely  be  detected. 

In  cysts  of  the  kidney — those  at  least  enclosing  echinococci 
— small  vesicles  containing  the  characteristic  structures  of  the 
parasites  may  perhaps  be  detected.  Ordinary  cysts  are  not  to  be 
recognized  with  any  certainty  during  life;   nor  can  they  be  dis- 

*  Ebstein,  Diseases  of  the  Kidneys,  in  Ziemssen's  Cyclopaedia. 


692 


MEDICAL    DIAGNOSIS. 


tinguished  from  Bright's  disease,  since  they  are  very  frequently 
developed  in  the  chronic  varieties  of  this  disorder.  When  the 
cysts  attain  decided  dimensions,  they  give  rise  at  times  to  the  dis- 
charge of  highly  bloody  urine,  and  to  albuminuria,  and  to  large 
tumors,  which  may  be  detected  through  the  front  walls  of  the 
abdomen.  They  may  affect  one  or  both  kidneys,  producing  slow 
cachexia  and  enormous  abdominal  swelling. 

Having  now  treated  of  chronic  Bright's  disease  as  one  affection, 
I  shall  briefly  refer  to  the  distinctions  between  its  forms.  In  so 
doing,  I  shall  fullow  the  classification  of  the  English  physicians, 
which  is  chiefly  based  on  the  diversified  anatomical  aspect  of  the 
kidneys. 

First  there  is  the  chronic  enlargement  of  the  organ,  of  which 
several  kinds  exist : 

1.  The  fatty  kidney,  pre-eminently  Bright's  disease.  The 
kidney  is  very  large  and  fatty.  The  deposit  may  occasion  yellow 
scattered  granulations,  or  the  enlarged  organ  is  pale,  and  mottled 
by  red  vascular  patches.     The  convoluted  tubes  are  filled  with 

Fig.  47. 


Tatty  casts  and  epithelial  cells  filled  with  fat,  as  seen  in  the  discharge  coming 
from  a  highly  fatty  kidney. 


oil,  accumulated  in  their  epithelial  cells.  The  fatty  disease  is 
recognized  by  the  numerous  oily  casts,  fatty  cells,  and  free  oil-cells 
which  appear  in  the  highly  albuminous  urine.  It  is  a  perilous 
complaint, — perhaps  the  most  fatal  of  all  the  forms  of  the  malady, 
— is  generally  very  chronic  in  its  course,  and  attended  with  per- 


THE  URIXE  AXD  DISEASES  OF  THE  URINARY  ORGAN'S.    693 

sistent  dropsy.  This  morbid  condition  must  not  be  confounded 
with  a  simply  fatty  kidney,  such  as  is  sometimes  found  in  phthisis, 
or  oftener  in  drunkards,  and  which  is  not  associated  with  albu- 
minous urine.  A  certain  amount  of  fatty  casts  and  fatty  cells 
may  appear  in  the  urine,  and  not  be  persistent  or  indicate  the  real, 
dangerous  fatty  kidney.  It  is  thought  by  seyeral,  by  Dickinson 
especially,  that  the  fatty  kidney  may  follow  a  high  degree  of  in- 
flammation in  the  acute  form  of  Bright's  disease,  particularly  in 
that  form  brought  on  by  exposure  to  cold.  The  acute  form  attend- 
ing scarlet  feyer  is  more  apt  to  pass  into  the  large  white  kidney. 

2.  The  enlarged,  chronically  inflamed  kidney.  I  allude  to  the 
chief  form  of  the  large  white  kidney  so  frequently  mentioned  by 
English  physicians.  This  is  probably  the  chronic  non-desquama- 
tive  nephritis  of  Johnson  ;*  it  is  the  kidney  represented  by  the 
third,  fourth,  and  fifth  forms  of  Raver's  albuminous  nephritis,f 
and  by  the  chronic  parenchymatous  inflammation  of  the  kidneys 
of  most  of  the  German  writers ;  it  is  the  chronic  form  of  the  tubal 
nephritis  of  Dickinson.  The  organ  is  white,  enlarged,  dense;  its 
tubes  are  filled  with  exudation-matter,  their  walls  thickened.  The 
cortical  portion  of  the  kidney  is  pale,  and  increased  in  breadth, 
evidently  full  of  an  inflammatory  deposit ;  the  medullary  cones 
retain  their  vascularity.  This  variety  of  the  malady  often  follows 
acute  Bright's  disease.  It  may  last  for  a  few  years,  but  generally 
terminates  unfavorably  before  that  time.  The  urine  is  diminished 
in  urea  and  pigment,  but  the  chlorides  are  normal;  it  contains 
granular,  epithelial,  and  some  hyaline  casts,  and  a  few  slightly  oily 
casts.  The  dropsy  the  disease  occasions  is  very  extensive  and  per- 
sistent, and  there  is  usually  little  difficulty  in  tracing  it  to  an  acute 
attack.  Sometimes  the  dropsy  lessens  materially,  then  actively 
recurs,  and  there  seem  to  be  rather  a  series  of  subacute  attacks 
than  a  continuous  chronic  malady.  The  large  kidney  is  not  sup- 
posed ever  to  contract;  but  this  is  not  a  settled  point.  Grainger 
Stewart  holds  that  it  does,  as  does  the  Avaxy  kidney,  yet  believes 
that  both  in  a  stage  of  atrophy  are  distinct  from  the  so-called 
cirrhotic  or  contracting  form  of  Bright's  disease.!  The  large 
white  kidney  may  pass  into  the  fatty  kidney. 

*  Diseases  of  the  Kidney. 

f  Traite  cles  Maladies  des  Reins,  tome  ii.  and  Atlas. 

j  On  Bright's  Disease  of  the  Kidneys,  1871. 


694  MEDICAL    DIAGNOSIS. 

3.  The  waxy  or  amyloid  kidney,  an  affection  in  which  the  en- 
larged organ  is  smooth,  of  firm  look,  and  of  pale-yellow  color,  and 
is  the  result  of  a  general  disease  involving  the  kidneys  in  common 
with  other  organs.  It  originates  in  the  exudation  from  the  mi- 
nute  arteries  of  a  waxy  material  which  infiltrates  the  tissues.    This 

Fig.  48. 


Hyaline  or  waxy  casts,  magnified  about  4G0  diameters.  On  some  of  them  are 
scattered  a  few  shrivelled  epithelial  cells  and  oil-drops;  the  large  cells  to  the 
left  arc  epithelial  cells  from  the  bladder. 

The  kind  of  casts  here  depicted  may  be  found  in  any  form  of  Bright's  disease, 
acute  as  well  as  chronic.  In  the  waxy  kidney,  however,  they  vastly  preponder- 
ate, and  are  of  large  size, — many  much  larger  than  those  in  this  figure. 

disease,  as  Dickinson  ably  enforces,*  very  generally  follows  upon 
protracted  suppuration  from  whatever  cause,  either  wound  or  dis- 
ease, as  dysentery  or  phthisis.  The  urine  is  increased  in  quantity 
in  the  earlier  stages,  and  contains  much  albumen,  but  not  many 
casts.  Those  which  are  seen  are  pale,  and,  for  the  most  part,  trans- 
parent, or  highly  refracting,  structureless  moulds  of  the  tubules, 
generally  of  large  diameter ;  they  may  or  may  not  give  the  char- 
acteristic amyloid  reaction,  the  red  color  when  treated  with  a 
watery  solution  of  iodine  and  of  iodide  of  potassium. f  Blood  is 
but  rarely  present  in  the  urine,  and  the  urea  is  but  slightly  di- 

*  Med.-Chir.  Trans.,  vol.  1.  page 30;  also  Path,  and  Treat,  of  Albuminuria. 

f  Curschmann  (Yirchow's  Archiv,  vol.  Ixxix.  part  3)  has  discovered  that 
methyl-green  has  a  peculiar  affinity  for  amyloid  substances,  and  colors  them 
an  intense  green.  It  is  used  for  staining  in  the  form  of  a  one  per  cent, 
aqueous  solution.  Methyl-green  colors  so-called  hyaline  casts  in  situ  ultra- 
marine blue,  so  that  these  also  can  be  readily  distinguished  in  sections  of  the 
kidney  from  the  green-colored  tissues  around,  in  which  they  may  lie. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    695 

minished  in  quantity.  Diarrhoea  frequently  coexists,  and  the  liver 
and  spleen  are  apt  to  be  enlarged;  but  the  heart  is  not  affected. 
The  dropsy  is  absent  or  trifling  in  amount,  yet  its  persistence  while 
the  urine  is  increased  in  quantity  is  peculiar  to  this  form  of  renal 
disease,  and  it  may  exist  markedly  as  a  late  symptom  ;  the  patient 
is  sallow-looking  and  emaciated ;  his  disease  may  last  for  years. 

In  laying  stress  on  the  hyaline  and  waxy  casts  we  must  be  care- 
ful not  to  confound  them  with  those  still  larger  mucous  moulds  of 
the  uriniferous  tubules,  or  mucous  casts,  which  Beale  has  so  particu- 
larly described.  They  are  also  smooth,  but  of  enormous  length, 
subdividing  into  smaller  ones.  They  are  particularly  apt  to  occur 
in  consequence  of  transmitted  irritation  from  the  bladder,  and  are 
then  perhaps  associated  with  small  amounts  of  albumen  and  of 
pus.  But  unless  the  latter  ingredient  be  present  there  is  no  albu- 
men, or  the  merest  trace. 

4.  Then  we  have  the  small  contracted  kidney,  which  is  viewed 
as  the  last  stage  of  Bright's  disease  by  those  who  believe  in  the 

Fig.  49. 


Granular  casts,  or  casts  covered  with  disintegrating  epithelium  and  granules. 
Casts  of  this  character  are  chiefly  found  in  the  chronic  inflammatory  forms  of 
Bright's  disease.  They  are  not  seen  in  the  acute  complaint,  except  when  it  is 
assuming  a  chronic  form. 

various  appearances  being  only  successive  stages  of  the  same 
morbid  process.  This  form  of  disease  is  frequently  found  in  gouty 
persons,  or  after  prolonged  mental  anxiety  and  distress.*  It  has 
repeatedly  been  noticed  as  the  result  of  lead-poisoning.     The  urine 


*  Clifford  Allbutt,  Brit,  and  For.  Med.-Chirurg.  Eeview,  Oct.  1877. 


696 


MEDICAL    DIAGNOSIS. 


contains  but  an  inconsiderable  amount  of  albumen;  the  tube-casts 
are  granular,  or  simple  fibrinous  moulds,  generally  small,  some- 
times large;  here  and  there  a  little  oil  is  observed.  Dropsy  is  ab- 
sent in  a  certain  proportion  of  cases,  and  when  present  is  generally 
slight.  It  often  disappears  for  a  while  and  returns.  The  urine  is 
increased  in  quantity,  although  toward  the  termination  it  may  be- 
come scanty  or  even  suppressed.  Dyspepsia,  puffy  eyelids,  chronic 
bronchitis,  headache,  and  disorder  of  the  nervous  system  are  com- 
mon symptoms.  The  malady  runs  a  very  chronic  course.  It  is 
chiefly  characterized  anatomically  by  an  affection  of  the  fibrous 
tissue  surrounding  the  Malpighian  corpuscles  and  lying  between 
the  tubes,  a  slow  increase,  followed  by  a  slow  contraction,  of  the 
intertubular  fibrous  tissue  and  atrophy  of  the  tubules,  and  con- 
nective-tissue changes  in  the  renal  plexus.*  The  sphygmograph, 
as  Mahomed  and  others  have  proved,  shows  marked  pulse-tension, 
and  this,  with  altered  specific  gravity,  has  been  noticed  before 
albumen  is  present  in  the  urine. 

In  the  following  table  the  clinical  differences  between  the  various 
forms  of  Bright's  disease  are  set  forth : 


Table  exhibiting  the   Clinical   Differences  between  the  Prin- 
cipal Forms  of  Bright's  Disease. 

Acute  Cases  in  which  Dropsy  occurs  quickly  and  is  extensive. 


Acute  Bright's 
disease ;  acute 
desquamative 
or  tubal  ne- 
phritis ;  acute 
parenchyma- 
tous nephritis ; 
acute  renal 
dropsy 


f  Caused  mostly 
by  exposure,  or 
scarlet  fever. 

|  Dropsy  exten- 
sive, generally 
begins  in  the 
eyelids  or  in 
the  feet ;  usu- 
ally febrile 
symptoms  ; 
uraemia  may  be 
met  with. 
Recoveries  fre- 
quent; but  dis- 
ease may  ter- 
minate in  the 
large  white 
kidney. 


f  Urine  usually  f 
scanty,  deep- 
colored,  of 
high  specific 
gravity,  con- 
taining much 
albumen,  often 
blood ;  also 
blood-casts  ; 
casts,  many  of 
large  size,  cov- 
ered with  epi- 
thelium, and 
a  few  hyaline 
casts  ;  and  free 
epithelial  cells, 
cloudy        and 

^      granular. 


Kidneys  en- 

larged and 
vascular,  con- 
gested or  mot- 
tled, shedding 
their  epithe- 
lium ;  cortical 
substance  in- 
creased ;  cones 
usually  redder 
than  cortical 
substance.  Tu- 
bules darker 
and  denser 
than  normal. 


*  Da  Costa  and  Longstreth,  Amer.  Journ.  of  Med.  Sciences,  July,  1880. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    697 

Table   exhibiting  the   Clinical   Differences  between  the   Prin- 
cipal Forms  of  Bright's  Disease — Continued. 

Chronic  Cases  in  which  Dropsy  is  variable  in  amount  and  may  be  absent. 


Chronic  inflam- 
matory form  ; 
chronic  tubal 
nephritis; 
large  white 
kidney 


History  often  of  f 
antecedent 
acute  inflam- 
matory attack; 
dropsy  a  prom- 
inent symp- 
tom. Uraamic 
phenomena 
not  uncom- 
mon ;  among 
them  at  times 
ursemic  coma, 
with  its  usual 
symptoms.  - 
Inflammations 
of  serous  mem- 
branes also  not 
uncommon. 

Hypertrophy  of 
heart,  espe- 
cially of  the 
left  ventricle. 

Recovery  possi- 
ble but  doubt- 
ful ;  may  pass 
into  fatty  kid- 
ney. 


Urine  in  normal 
or  in  increased 
quantity ;  al- 
bumen gener- 
ally in  con- 
siderable 
amount ;  gran- 
ular epithelial 
casts ;  some 
hyaline  casts  ; 
at  times  com- 
pound granule 
cells  and  par- 
tially fatty  ep- 
ithelium ;  casts 
with  f  r  a  g- 
ments  of  epi- 
thelium or  a 
little  fat ;  no 
blood-casts. 


f 


Kidneys  en- 
larged, cap- 
sules easily 
stripped  off, 
cortical  sub- 
stance in- 
creased in  vol- 
ume, cones 
may  be  of  nat- 
ural color ; 
tubes  often 
irr  egularl  y 
distended,  and 
filled  with 
granular  epi- 
thelium here 
and  there 
slightly  fatty. 


Fatty      Bright's 
kidney 


Persistent  and 
obstinate  drop- 
sy, coming  on 
gradually; 
face  pale  and 
puffed ;  hyper- 
trophy  of 
heart  affect- 
ing often  both 
sides. 

Always  fatal. 


f  Urine  contains 
much  albu- 
men, fatty 
casts,  fatty  epi- 
thelial cells, 
free  oil. 

Spec.  grav.  vari- 
able, usually 
from  1015  to 
1030. 

Quantity  vari- 
able, generally 
moderate  or 
diminished ; 
urea  dimin- 
ished. 


Kidneys  en- 

larged and 
very  fatty  ; 
sometimes 
have  a  mottled 
look. 

The  tubes,  espe- 
cially the  con- 
voluted ones, 
full  of  highly 
fatty  epithe- 
lium, and  free 
oil. 


698 


MEDICAL    DIAGNOSIS. 


Chronic  Cases  in  which  Dropsy  is  variable  in  amount  and  may  be  absent- 
Continued. 


Waxy  kidney ; 
lardaceous  or 
amyloid  de- 
generation of 
kidney  


Follows  usually  ex- 
hausting diseases, 
syphilis,  caries, 
and  long-contin- 
ued suppuration. 
|  Dropsy  trifling,  ex- 
cept late  in  dis- 
ease ;  great  ema- 
ciation ;  striking 
sallowness  of  face; 
liver  and  spleen 
enlarged ;  diar- 
rhcea ;  much 

thirst ;  heart  not 
affected ;  nervous 
symptoms  infre- 
quent. 
Unfavorable  prog- 
nosis. 


Chronic  con- 
traction of 
the  kidney : 
cirrhosis  of 
the  kidney ; 
interstitial 
nephritis; 
granula  r 
kidney; 
gouty  kid- 
ney. 


Urine  increased, 
contains  much 
albumen,  hut 
few  casts, 
-which  are  pale 
and  transpa- 
rent or  highly 
refracting. 
The  casts  may 
or  may  not 
give  the  ma- 
hogany-red re- 
action with  a 
watery  solu- 
tion of  iodine. 

Spec.  grav.  low, 
yet  usually 
above  1010 ; 
urea  normal  or 
slightly  dimin- 
ished. 


f  Dropsy  moderate, 
may  be  absent ; 
face  sallow,  yet 
not  so  much  so 
as  in  the  waxy 
disease ;  often 

headache  and  re- 
tention of  urea, 
tendency  to  coma, 
and  to  convul- 
sions;  impover- 
ished blood ;  hy- 
p  e  r  t  r  o  p  h  y  of 
heart :  epi.-taxis  ; 
liver  may  be  cir- 
rhosed ;  retinitis. 
May  exist  for  years 
unsuspected ;  is  a 
very  chronic  dis- 
ease, and  incura- 
ble ;  may  lead  to 
death  by  apo- 
plexy. 


Kidneys  en- 
larged,smooth, 
and  wax  y- 
looking ;  red- 
dish -brown 
discoloration 
on  testing  with 
watery  solu- 
tion of  iodine. 


Urine  more  copi- 
ous than  in 
health,  yet  ex- 
tremely small 
amount  of  al- 
bumen, this  at 
times  tempo- 
rarily absent ; 
hyaline  and 
large  finely 
granularcasts : 
altered  epithe- 
lium;  a  little 
oil. 

Spec.  grav.  low ; 
rarely  above 
1010,  much 
oftener  below ; 
urea  not  de- 
creased until 
late  in  disease. 


Kidneys  waste 
slowly,  become 
dense  and  con- 
tracted ;  cap- 
sule very  ad- 
herent ;  thick- 
ness of  the  cor- 
tical substance 
diminished  ; 
cysts  common. 
There  is  hyper- 
trophy of  con- 
nective tissue ; 
atrophy  of 
gland  elements 
and  of  tubules. 
Tissue  changes 
in  renal  gan- 
glia. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    699 

Diseases  associated  with  Purulent  Urine, 

There  is  a  group  of  affections  in  which  pus  is  found  in  the  urine, 
and  in  which  the  presence  of  this  abnormal  ingredient  becomes  of 
great  value  in  diagnosis;  yet  to  distinguish  the  individual  mem- 
bers of  the  group  from  one  another,  and  to  ascertain  the  source  of 
the  purulent  urine,  we  have  to  look,  for  the  most  part,  to  the 
other  symptoms.  In  every  case  in  which  pus  in  any  quantity  is 
detected  in  the  urine,  it  becomes  of  great  importance  to  ascertain 
primarily  that  it  is  not  derived  from  the  urethra,  from  the  vagina, 
or  from  an  abscess  that  has  opened  into  the  urinary  passages.  The 
first  point  we  may  decide  by  examining  into  the  history  of  the 
case,  and,  if  necessary,  by  an  exploration  of  the  parts,  as  well  as 
by  an  examination  of  the  urine  procured  in  the  manner  recom- 
mended in  the  first  part  of  this  chapter;  the  second,  by  the  same 
means,  and  by  determining  that  a  discharge  takes  place  equally 
when  no  urine  is  voided ;  the  third  is  more  difficult  to  make  out, 
but  there  is  generally  something  in  the  symptoms  and  in  the  his- 
tory of  the  case  furnishing  a  clue  to  its  interpretation, — such,  for 
instance,  as  the  sudden  appearance  of  a  large  quantity  of  pus  in 
the  urine.  Having  excluded  each  of  these  morbid  states  as  the 
source  of  the  purulent  urine,  we  next  turn  to  see  which  of  the 
maladies  that  are  its  most  common  cause  is  before  us.     They  are : 

Acute  Cystitis. — Acute  inflammation  most  frequently  affects 
the  mucous  membrane  at  or  near  the  neck  of  the  bladder.  The 
inflammation  may  spread  from  the  mucous  membrane  to  the  mus- 
cular coat;  but  it  rarely  reaches  the  peritoneal  covering.  In  some 
cases  it  is  propagated  along  the  uterus,  and  even  to  the  kidneys. 
The  morbid  action  is  not  often  of  idiopathic  origin,  although  some- 
times it  follows  exposure  to  cold  and  damp;  much  more  usually 
is  it  due  to  the  extension  of  an  attack  of  gonorrhoea,  to  disease  of 
the  prostate,  to  traumatic  causes,  to  protracted  retention  of  urine, 
or  to  the  irritation  produced  by  medicines  or  stimulating  drinks. 
Sometimes  it  is  owing  to  the  poison  of  rheumatism  or  of  gout. 

Acute  cystitis  is  much  more  frequently  encountered  in  men  than 
in  women,  and  in  adults  than  in  children.  Its  main  symptoms 
are  a  feeling  of  weight  and  pain  in  the  hypogastric  region,  aug- 
mented by  movement  and  by  pressure.  The  pain  does  not,  how- 
ever, remain  confined  to  the  region  about  the  bladder,  but  is  also 


700  MEDICAL    DIAGNOSIS. 

felt  in  the  iliac  and  sacro-lumbar  regions.  It  is  attended  with 
considerable  febrile  disturbance  and  extreme  irritability  of  the 
affected  viscus.  The  urine  is  voided  drop  by  drop,  and  its  passage 
is  usually  accompanied  by  straining  and  a  scalding  sensation  at 
the  neck  of  the  bladder;  it  is  high-colored,  cloudy  from  increased 
vesical  mucus,  and  contains  blood  and  pus  and  sometimes  shreds 
of  lymph.  The  acute  disease  generally  terminates  within  a  week, 
leaving  often  an  irritable  bladder  or  a  chronic  inflammation. 

The  symptoms  of  acute  cystitis  are  similar  to  those  of  acute 
nephritis,  and  the  exciting  causes  are  much  the  same.  But  acute 
inflammation  of  the  bladder  differs  from  acute  inflammation  of 
the  kidney  by  the  greater  severity  of  the  pain,  its  much  lower 
position,  and  the  distress  occasioned  in  voiding  the  urine.  Neu- 
ralgia, or  spasm,  of  the  bladder  may  be  distinguished  from  acute 
inflammation  by  the  absence  of  fever,  and  the  sharp,  lancinating, 
but  paroxysmal  pain  of  the  former  malady,  each  onset  of  which 
lasts  hardly  longer  than  from  two  to  six  hours,  and  is  attended 
with  difficulty  in  making  water,  which,  however,  disappears  as  the 
pain  subsides. 

Metritis  exhibits  several  of  the  traits  of  cystitis:  we  find  the 
same  hypogastric  pain  shooting  downward  to  the  thighs  or  toward 
the  anus  and  loins,  the  same  feeling  of  weight  in  the  peritoneum, 
and  the  same  signs  of  irritation  of  the  bladder  and  of  fever.  As 
it,  however,  generally  occurs  in  the  puerperal  state,  we  have  the 
history,  and,  moreover,  the  character  of  the  discharges  from  the 
vagina,  to  guide  us,  and,  should  doubt  still  exist,  the  knowledge 
to  be  gained  by  a  digital  and  a  specular  examination. 

Chronic  Cystitis. — This  affection,  often  called  chronic  vesical 
catarrh,  is  common  in  advanced  age.  It  generally  comes  on  in 
an  insidious  manner,  and  is  excited  by  some  obstacle  to  the  evacu- 
ation of  urine,  such  as  a  stricture,  or  by  the  presence  of  a  stone 
in  the  bladder,  or  by  an  enlargement  of  the  prostate  gland.  A 
paralysis  of  the  viscus  leading  to  retention  of  its  contents,  or  a 
serious  structural  disease  of  its  coats,  whether  malignant  or  non- 
malignant,  may,  however,  also  establish  the  morbid  process. 

The  symptoms  are  partly  those  of  constitutional  debility,  partly 
those  of  local  disease.  The  most  usual  of  the  latter,  indeed  in 
every  way  the  most  characteristic  of  the  malady,  are  the  dull 
pain,  a  frequent  desire  to  make  water,  and  the  passage  of  a  large 


THE  TJEINE  AND  DISEASES  OF  THE  TJEINARY  ORGANS.    701 

quantity  of  muco-pus  or  pus  with  each  act  of  micturition.  The 
urine,  on  standing,  deposits  a  thick,  glairy,  viscid  sediment,  in 
which,  under  the  microscope,  triple  phosphates  and  large  pus 
corpuscles,  extremely  regular  both  in  contents  and  in  shape,  may 
be  detected. 

The  diagnosis  of  the  disease  in  males  is  easy.  The  only  affec- 
tion with  which  it  is  liable  to  be  confounded  is  abscess  of  the 
kidney.  In  females,  uterine  disorders  may  so  closely  simulate  it 
that  we  cannot  be  certain  of  the  existence  of  a  disease  of  the 
bladder  until,  by  careful  inquiry  into  the  history  of  the  case, 
and,  if  need  be,  by  aid  of  the  speculum,  we  have  ascertained  with 
accuracy  the  state  of  the  organs  of  generation. 

But,  having  decided  the  case  to  be  one  of  chronic  cystitis,  it 
is  always  more  difficult  to  discover  its  exciting  cause.  We  have 
to  depend,  to  a  great  extent,  upon  the  history  of  the  malady;  its 
association  with  a  stone  can  be  determined  only  by  the  use  of  the 
sound. 

Abscess  of  the  Kidney. — This  dangerous  condition  is  the 
result  of  suppurative  inflammation  of  the  kidney,  or  of  abscesses 
forming  in  connection  with  pyaemia,  or  embolism.  The  suppu- 
rative inflammation  is  sometimes  traceable  to  an  acute  attack  of 
nephritis  brought  on  by  exposure  or  external  violence,  to  reten- 
tion of  urine,  or  to  the  impaction  of  a  renal  calculus ;  but  at  other 
times  it  originates  without  any  assignable  cause,  and  in  a  very  in- 
sidious way.  The  association  of  suppurative  nephritis — "  surgical 
kidney" — with  erysipelas  has  recently  engaged  much  attention, 
and  the  renal  affection  is  even  thought  to  be  erysipelatous  in  its 
origin.* 

"When  the  disorganizing  process  has  continued  for  some  time, 
and  the  abscesses  are  fairly  formed,  we  encounter  these  signs :  a 
fulness  on  one  side  of  the  spine  in  the  lumbar  region,  associated 
with  tenderness  on  deep  pressure  and  with  more  or  less  constant 
pain,  the  pain  and  tenderness  being  increased  by  lying  on  the 
affected  side;  fever  and  occasional  rigors;  digestive  disturbances, 
and  the  presence  of  blood  and  pus  in  the  scanty  urine.  In  some 
cases  a  marked  tumor  is  found  in  the  loin,  extending  toward  the 
iliac  fossa.     If  the  abscess  burst  into  the  calices,  there  occurs, 

"*  Goodhart,  Guy's  Hospital  Keports,  3d  Series,  vol.  xix. 


702  MEDICAL    DIAGNOSIS. 

simultaneously  with  a  subsidence  of  the  tumor,  a  sudden  and 
copious  discharge  of  pus  with  the  urine,  or,  if  it  break  into  the 
intestine,  with  the  frecal  evacuation. 

The  disease  almost  never  affects  more  than  one  kidney :  hence 
so-called  uremic  symptoms  are  rarely  met  with,  since  the  healthy 
kidney  enlarges  and  becomes  capable  of  performing  a  double 
amount  of  work.  The  disorder  gradually  leads  in  most  cases  to 
a  fatal  issue,  from  the  irritation,  the  vomiting,  the  diarrhoea,  the 
wasting  discharge,  and  the  protracted  hectic;  sometimes  paralysis 
of  one  or  both  legs  happens,  adding  greatly  to  the  distress.  There 
is  a  possibility  of  recovery  if  the  patient  have  strength  enough  to 
withstand  the  purulent  drain  until  the  abscess  empties  itself.  Tt 
may  do  this  through  the  urinary  passages,  through  the  colon, 
through  the  lumbar  muscles,  through  the  diaphragm,  and  be 
evacuated  by  coughing,  and  the  cavity  of  the  abscess  then  cica- 
trizes; or  the  abscess  may  burst  into  the  peritoneal  cavity  and 
cause  rapid  death. 

The  diseases  for  which  the  malady  is  most  apt  to  be  mistaken 
— leaving  out  those  extremely  rare  cases  in  which  abscesses  from 
diseased  vertebra  break  suddenly  into  the  urinary  tract — are 
chronic  cystitis,  perinephritis,  and  pyelitis.  From  cystitis  it  may 
be  distinguished  by  the  dissimilar  local  signs  and  the  different 
appearances  of  the  urine.  Thus,  in  the  affection  of  the  bladder 
the  quantity  of  pus  constantly  discharged  is  far  greater, — for  in 
abscess  of  the  kidney  there  are  times  when  but  little  or  no  pus  is 
voided;  on  the  other  hand,  the  urine  of  the  vesical  disorder  is  less 
albuminous.  Yet  this  is  not  a  certain  guide,  for  we  may  have 
a  Bright's  kidney  associated  with  a  catarrh  of  the  bladder,  and 
thus  both  a  highly  purulent  and  a  highly  albuminous  urine  be 
produced.  In  this  case,  however,  a  diligent  search  with  the  micro- 
scope will  detect  casts  and  other  renal  products  in  the  sediment. 

Perinephritis  unconnected  with  inflammation  of  the  kidney  is 
a  very  rare  disease.  When  primary,  it  may  result  from  exposure ; 
but  it  is  more  generally  due  to  contusion  or  strain.  I  saw  an  in- 
stance of  it  which  occurred  in  a  young  gentleman  who,  returning 
home  from  a  long  walk,  strained  his  back  in  jumping  a  fence. 
An  abscess  very  gradually  formed,  giving  rise  to  a  slight  fulness 
in  the  left  lumbar  region,  and  severe  pain,  which  disappeared  as 
matter  was  discharged  through  the  integuments.     The  function 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.     703 

of  the  kidney  was  not  affected  :  proving  that  the  disorder  was  in 
the  neighborhood,  and  not  in  the  structure,  of  the  organ.* 

But  an  external  opening  may  be  established  when  the  process 
of  inflammation  and  suppuration  has  begun  in  the  kidney  and 
thence  spread  to  the  loose  tissues  surrounding  it.  Under  these 
circumstances,  the  appearance  in  the  urine  of  pus  prior  to  its  dis- 
charge through  the  muscles  of  the  back  would  be  the  only  certain 
means  by  which  we  could  judge  where  the  suj)puration  had  pri- 
marily taken  place.  The  inflammation  may  also  travel  upward 
from  the  pelvic  viscera  or  from  the  head  of  the  colon ;  it  has 
not  unfrequently  been  noticed  after  irritation  of  the  testicles  and 
of  the  spermatic  cord.  Secondary  perinephritis  has  been  observed 
after  typhoid  and  typhus  fevers  and  smallpox. 

The  prominent  symptom  in  perinephritis  is  pain,  which  at 
times  is  so  severe  as  to  confine  the  patient  to  bed  with  knees 
flexed,  with  a  sense  of  fulness  and  dragging  weight,  with  ten- 
derness in  the  region  of  the  kidney,  and  with  lameness  owing  to 
the  interference  with  the  play  of  the  psoas  muscles.  The  urine 
is  generally  unaltered,  or  only  full  of  urates ;  the  bowels  may  be 
constipated,  owing  to  the  pressure  of  the  tumor  on  the  intestine. 
A  rounded,  doughy,  and  generally  indolent  tumor,  uninfluenced 
by  the  respiratory  movements,  is  usually  found  in  the  lumbar 
region  or  a  little  lower.  In  Bowditch's  cases  the  abscess  extended 
up  into  the  right  pleura,  without  apparently  affecting  the  liver, 
after  having  probably  forced  its  way  behind  that  organ  and  along 
the  psoas  muscles  under  the  right  crus  of  the  diaphragm,  and 
caused  pulmonary  or  pleuritic  complications,  but  not  jaundice. 
As  the  disease  advances,  severe  chills,  with  high  fever  and  copious 
night-sweats,  occur,  as  well  as  emaciation  and  marked  debility, 
and  the  thoracic  symptoms  may  mask  the  renal ;  fluctuation  may 
at  times  be  detected,  and,  before  the  abscess  breaks  externally,  a 
phlegmonous  appearance  of  the  skin  where  the  abscess  points  is 
not  unusual.    Great  relief  follows  the  discharge  of  the  pus. 

*  Trousseau,  in  his  Clinique  Medicale,  cites  several  instances  of  perinephritic 
abscess,  and  Bowditch  narrates  three  cases  in  the  Boston  Medical  and  Surgical 
Journal,  1868,  1ST.  S.,  vol.  i.  p.  357.  See  also  Brit,  and  For.  Med.-Chir.  Bev. 
July,  1871,  Bowditch,  Med.  and  Surg.  Kep.  Boston  City  Hospital,  1st  Series, 
and  Amer.  Journ.  of  Med.  Sci.,  April,  1871;  Duffin,  Med.  Times  and  Gaz„ 
1872,  vol.  ii. 


704  MEDICAL   DIAGNOSIS. 

From  inflammation  of  the  j^soas  muscle  we  distinguish  peri- 
nephritis by  the  absence  of  marked  sensitiveness  over  the  renal 
region  in  the  former  complaint,  and  by  flexion  of  the  thigh  in  it 
producing  pain. 

Pyelitis. — This  is  the  name  given  by  Rayer  to  inflammation 
of  the  mucous  membrane  of  the  pelvis  of  the  kidney, — an  affec- 
tion almost  never  idiopathic,  being  commonly  caused  by  a  calculus 
that  has  been  arrested  at  the  commencement  of  the  ureter,  or  by 
a  retention  of  urine  from  an  obstacle  in  the  ureter,  bladder,  or 
urethra,  or  by  an  extension  upward  from  the  bladder  of  an  in- 
flammation. Bright's  disease  and  diabetes  are  not  unusually,  and 
typhus  and  the  eruptive  fevers,  pyaemia,  scurvy,  diphtheria,  car- 
buncle, and  the  puerperal  state,  are  occasionally,  complicated  with 
some  degree  of  pyelitis.  In  some  instances  pyelitis  is  catarrhal 
or  rheumatic. 

The  symptoms  of  the  malady  are,  therefore,  in  part  those  pro- 
duced by  the  morbid  states  exciting  it,  especially  those  denoting  a 
calculus  lodged  in  the  kidney  or  arrested  in  its  transit  toward  the 
bladder ;  partly  those  directly  traceable  to  the  inflammation  of 
the  pelvis  and  infundibula.  The  manifestations  of  the  latter  dis- 
order are,  a  constant  pain  in  the  loin,  felt  also  in  the  course  of 
the  ureter,  and  the  passage  of  pus  and  occasionally  of  small 
quantities  of  blood  with  the  urine ;  in  cases  from  retention  and 
decomposition  of  urine  there  are  chills,  sweats,  vomiting,  headache, 
delirium,  and  a  low  fever.  In  most  cases  of  pyelitis  the  urine  is 
acid.  The  marked  exception  is  in  the  instances  last  mentioned, 
where  it  is  apt  to  be  ammoniacal  and  to  swarm  with  bacteria.* 

The  most  difficult  point  connected  with  the  recognition  of  pye- 
litis is  to  be  certain  that  the  purulent  discharge  does  not  proceed 
from  the  bladder.  And  there  is  no  positive  sign  to  guide  us,  ex- 
cept the  existence  in  the  urine  of  epithelium  from  the  pelvis 
of  the  kidney,  distinguishable  by  the  frequent  occurrence,  in  a. 
cell,  of  clearly-defined,  dark-colored,  round  granules,  and  of  two 
nuclei.  But  this  epithelium  may  not  always  be  found,  and  we 
have  then  to  fall  back  upon  the  history  of  the  case,  upon  the 
attacks  of  renal  pain,  upon  the  heematuria  caused  by  a  calculus, 
and  the  combination  of  signs  as  pointing  more  to  one  disease  than 

*  Ebstein,  art.  "  Pyelitis,"  in  Ziernssen's  Cyclopaedia. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.       705 

to  the  other.  In  some  cases  there  is  a  perceptible  swelling  in  the 
loin,  which  assists  ns  materially  in  coming  to  a  conclusion;  at 
times,  too,  owing  to  coexisting  congestion  or  degeneration  of  the 
kidney,  the  amount  of  albumen  is  wholly  disproportionate  to  that 
contained  in  pus,  and  this  becomes  a  valuable  indication  of  the 
affection  not  being  vesical.  But  if  there  be  a  coincident  disease 
of  the  bladder,  the  differential  distinction,  on  Rayer's  own  show- 
ing, becomes  impossible.  Recently,  an  Italian  author  has  brought 
forward  a  new  sign  of  pyelitis,  which  he  regards  as  certain.  It 
consists  in  taking  note  of  the  manner  in  which  nitrate  of  urea 
crystallizes  when  nitric  acid  is  added  to  the  urine.  If  the  catarrh 
be  limited  to  the  bladder,  the  microscope  shows  the  crystals  ar- 
ranged in  the  form  of  hexagonal  rhomboidal  blades ;  in  pyelitis 
the  blades  are  irregular  and  set  at  angles,  and  some  of  them  are 
in  the  shape  of  small  feathers.* 

Supposing  the  point  settled,  and  the  vesical  origin  of  the  pus  dis- 
proved, the  diagnosis  is  limited  to  an  inflammation  of  the  ureter, 
to  an  abscess  in  the  substance  of  the  kidney,  and  to  pyelitis. 
Here  again  the  history  of  the  case  comes  into  play.  Further- 
more, in  the  former  of  these  affections — a  very  rare  one,  unless 
associated  with  pyelitis — the  amount  of  pus  in  the  urine  is  very 
trifling;  in  the  second,  too,  it  is  less  than  in  pyelitis,  except 
when  the  abscess  empties  itself.  The  pus  is  also,  as  already  in- 
dicated, not  constant,  alternately  appearing  in  and  disappearing 
from  the  urine,  there  is  usually  more  obvious  swelling,  although 
this  is  by  no  means  always  discernible  or  even  present  in  abscess, 
and  the  abscess  is  attended  with  much  greater  constitutional  dis- 
turbance. Still,  here  again  we  must  admit  that  the  disorders  are 
sometimes  very  obscure  and  difficult  to  distinguish,  and  it  may  be 
impossible  to  discriminate  between  them  should  the  morbid  states 
coexist,  or  a  typhoid  condition  and  ursemic  fever  be  induced  by 
the  retention  of  the  urine  and  its  decomposition. 

Catarrhal  or  rheumatic,  pyelitis  is  generally  a  short  disease  which 
ends  favorably;  so  does  the  idiopathic  pyelitis  of  the  puerperal 
state,  which  rarely  lasts  more  than  from  five  to  eight  days.  The 
pyelitis  with  retention  and  decomposition  of  urine  is  a  much 
more  serious  complaint,  and,  although  it  may  and  usually  does 

*  Pascallucci,  II  Morgagni,  quoted  in  Lancet,  June,  1873. 
45 


706  MEDICAL    DIAGNOSIS. 

run  a  rapid  course,  not  having  a  duration  of  more  than  a  week 
or  two,  it  may  become  a  protracted  state.  Pyelitis  due  to  the 
irritation  of  calculi  is  apt  to  develop  into  a  chronic  condition. 

In  those  cases  of  pyelitis  in  which  there  is  a  very  decided  ob- 
struction to  the  flow  of  urine  through  the  ureter,  caused  by  a  cal- 
culus, clot  of  blood  or  viscid  pus,  or  other  debris,  the  discharge  of 
pus  is  suddenly  arrested  and  the  cavity  of  the  pelvis  dilates  greatly; 
gradually  the  gland-tissue  is  compressed,  and  a  large  pus-contain- 
ing sac  is  formed,  giving  rise  to  a  condition  known  as  pyonephrosis, 
and  to  a  distinctly  limited  swelling  in  the  side.  Tumors  of  this 
kind  are  ordinarily  not  painful  to  the  touch,  are  sometimes  very 
indolent,  and  do  not  materially  affect  the  general  health,  certainly 
not,  as  a  rule,  nearly  as  much  as  might  be  supposed.  They  not 
unfrequently  subside  gradually  by  free  discharges  of  pus,  and  the 
patient  recovers.*  Sometimes  they  become  much  reduced,  and 
then  swell  up  again  from  time  to  time.  They  have  been  known 
to  occur  in  both  kidneys ;  but  this  is  of  great  rarity. 

Pyonephrosis  cannot  be  distinguished  from  suppurative  nephritis 
and  ordinary  abscess  of  the  kidney,  except  it  be  by  the  history. 
The  more  constant  and  larger  discharge  of  pus  may  also  be  made 
a  point  of  diagnosis,  as  well  as  the  obvious  variations  in  the  swell- 
ing and  the  slighter  constitutional  symptoms.  But  too  much 
stress  must  not  be  laid  on  these  points ;  and  the  fact  should  not 
be  overlooked  that  abscess  of  the  kidney  may  be  latent,  be  present 
almost  without  fever,  or  with  very  obscure  manifestations  of  pain, 
— irregular  attacks  of  fever,  and  vomiting,  coming  on  at  intervals 
for  months  or  years. 

When  the  changes  resulting  from  an  impediment  to  the  flow  of 
urine  are  unassociated  with  suppuration  of  the  mucous  membrane 
of  the  pelvis  of  the  kidney,  although  the  pelvis  dilates  extraor- 
dinarily and  the  kidney-tissue  in  time  disappears,  we  have  the 
condition  designated  by  Payer  as  hydronephrosis.  It  is  often  due 
to  retroflexion  or  to  cancer  of  the  womb,  to  morbid  growths  or  to 
abscess  of  the  bladder,  or  to  congenital  malformation  of  the  ureter. 
Sometimes  it  is  double.  The  swelling  to  which  it  gives  rise  may 
subside  simultaneously  with  a  sudden  and  copious  discharge  of 


*  See,  for  instance,  Cases  XLVIII.  and  L.  in  Todd's  Clinical  Lectures  on 
the  Urinary  Organs. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.     707 

urine.  When  this  symptom  is  absent,  the  diagnosis  must  be  based 
on  the  existence  of  a  fluctuating  renal  tumor  and  on  the  absence  of 
signs  of  suppuration.*  It  may  lead  to  temporary,  but  entire,  sup- 
pression of  urine.  Accurate  percussion  enables  us  to  distinguish 
hydronephrosis  from  ascites;  in  the  former  the  dulness  is  generally 
one-sided,  and  it  is  uninfluenced  by  change  of  position.  Ovarian 
cysts  are  more  difficult  to  discriminate.  Careful  examinations  by 
the  rectum  and  by  the  vagina,  and  an  investigation  of  the  fluid 
after  an  exploratory  puncture,  are  alone  of  value ;  and  even  they 
may  mislead.  Urinary  constituents,  for  instance,  have  been  found 
to  be  absent  in  rare  cases  of  hydronephrosis. 

Hydatid  tumor  of  the  kidney  is  of  comparatively  rare  occur- 
rence, and  is  very  apt  to  be  confounded  with  hydronephrosis. 
When  the  urine  contains  no  hydatid  vesicles  or  their  debris  and 
the  hydatid  fremitus  is  absent,  the  diagnosis  is  extremely  difficult, 
and  must  rest  chiefly  on  the  history  of  the  case. 

Ordinary  renal  cysts,  when  large  enough  to  occasion  a  tumor, 
cannot  be  distinguished  from  hydronephrosis  save  by  the  history, 
and  by  the  albuminous  and  bloody  urine  which  the  cysts  give  rise 
to,  while  in  hydronephrosis  the  urine  presents  nothing  peculiar, 
or  occasionally  only  small  amounts  of  pus. 

Pyelitis  may  be  connected  with  fibrinous  clots  due  to  repeated 
hemorrhages  from  multiple  aneurisms  of  the  renal  artery.  We  may 
suspect  this  condition  if  the  other  more  usual  causes  of  pyelitis 
seem  to  be  absent,  and  if  the  affection  happen  in  an  old  person 
having  repeated  attacks  of  hematuria  and  atheromatous  arteries,  f 

Disorders  in  which  a  very  large  Amount  of  Urine  is 

discharged. 

Diabetes. — An  excessive  flow  of  urine  was  formerly  called 

diabetes;  it  is  now  customary  to  restrict  the  term  to  the  excessive 

flow  accompanying  the  excretion  of  sugar,  the  diabetes  mellitus, 

or  glycosuria,  of  many  authors. 

Diabetic  urine  is  of  pale  color  and  of  high  specific  gravity, 
ranging  generally  from  1030  to  1050.  The  quantity  passed  is 
enormous :   seventy  pints  and  upward  have  been   known  to  be 

*  See  Schroeder,  Diseases  of  the  Female  Sexual  Organs,  p.  385. 
f  Ollivier,  Archives  de  Physiologie,  1873. 


708  MEDICAL    DIAGNOSIS. 

discharged  daily.  The  urea  is  generally  increased,  when  altered 
at  all,  so  are  the  sulphates  and  the  chlorides,  and  the  earthy  phos- 
phates, while  the  alkaline  phosphates  vary  greatly  with  the  food, 
and  uric  acid  is  probably  diminished. 

The  symptoms  attending  the  drain  of  fluid  from  the  system 
are,  as  may  be  supposed,  great  thirst,  constipation,  and  generally 
a  dry,  harsh  skin,  and  a  feeling  of  constant  emptiness  and  of 
hunger.  To  these  are  added  a  steadily  progressing  waste  of  the 
body,  debility,  chills,  a  somewhat  hurried  breathing,  peevishness 
of  temper,  and  a  tendency  to  boils  and  carbuncles.  Cataract  and 
other  kinds  of  defective  vision  are  not  infrequent.  Galezowski* 
has  described  a  form  of  retinitis  which  has  been  observed,  in  some 
rare  cases,  to  accompany  diabetes;  retinal  hemorrhage  and  pal- 
sies of  the  muscles  of  the  eyeball  have  also  been  noticed.  Re- 
cently attention  has  been  directed  to  diabetic  hypermetropia,  and 
with  the  change  of  refraction  a  quantity  of  sugar  in  the  urine 
was  observed.! 

Diabetes  is  a  very  fatal  disease;  yet  it  is  impossible  to  foretell 
its  exact  mode  of  termination.  Some  are  cut  off  rather  suddenly; 
others  drag  out  a  long  existence,  and  die  worn  out  and  dropsical, 
or  of  superadded  phthisis.  For  some  days,  or  even  for  weeks, 
before  death,  the  sugar  may  disappear  from  the  urine.J 

Whence  comes  the  sugar?  Is  it  from  the  food,  the  blood,  the 
kidneys,  the  stomach,  the  liver?  These  are  questions  that  cannot 
be  satisfactorily  answered.  Since  Bernard's  discovery  of  the  sugar- 
forming  properties  of  the  liver,  saccharine  urine  is  thought  to  pro- 
ceed from  an  inordinate  formation  in  this  viscus  of  sugar,  which 
is  not  fully  destroyed  in  the  lungs,  and  is  excreted  by  the  kidneys. 
But  the  experiments  of  Pavy  seem  to  throw  some  doubt  on  this 
simple  and  ingenious  theory.  That  the  sugar  is  not  derived  from 
the  food  is  very  certain ;  for  patients  kept  even  on  the  most  rigor- 
ous meat  diet  still  pass  sugar.  In  some  cases  diabetes  has  been 
observed  to  be  associated  with  paralysis  of  the  tongue,  palate,  and 
vocal  cord,  and  other  signs  of  disease  in  the  floor  of  the  fourth 


*  Compte-Eendu  du  Congres  Ophth.  de  Paris,  18G2. 

f  Landolt,  "  El  Siglo  Medico,"  quoted  Lancet,  April,  1880. 

X  In  a  case  for  a  long  time  under  my  charge,  in  which  the  diabetes  lasted 
for  several  years,  sugar  entirely  disappeared  from  the  urine  as  the  signs  of 
phthisis  became  fully  developed,  and  for  several  months  before  death. 


THE  UEINE  AND  DISEASES   OF  THE  URINARY  ORGANS.     709 

ventricle,  or  of  tumors  pressing  there ;  or  it  has  been  noticed  after 
fractures  of  the  skull  involving  the  base;  and  in  recent  publi- 
cations Dickinson  has  adduced  much  evidence  of  the  frequent 
connection  of  diabetes  with  alterations  of  the  nervous  system.* 
Again,  diabetes  in  a  number  of  cases  has  been  found  to  be  linked 
to  a  lesion  of  the  pancreas.  It  also  often  follows  mental  emotion. 
In  some  instances  it  is  hereditary. 

Starchy  and  saccharine  substances  increase  the  quantity  of  dia- 
betic sugar.  Nay,  they  may  be  the  cause  of  a  little  sugar  ap- 
pearing in  the  urine  of  healthy  persons.  Yet  those  in  whom  a 
saccharine  state  of  the  urine  is  readily  induced  are  in  great  danger 
of  becoming  diabetic. 

In  the  aged,  sugar  may  be  present  in  the  urine  without  being 
attended  with  distressing  symptoms.  It  is  in  such  cases  that  we 
are  most  apt  to  meet  with  the  intermitting  diabetes  to  which 
attention  has  been  called  by  Bence  Jones. f  When  the  abnormal 
ingredient  thus  disappears  from  the  urine,  it  is  replaced  by  uric 
aeid  and  by  oxalates.  There  is  still  another  form  of  intermitting 
diabetes.  Sugar  is  sometimes — Burdel|  says  uniformly — found 
in  the  urine  during  the  paroxysms  of  intermittent  fever;  but  it 
vanishes  entirely  during  the-  intervals. 

Sugar  is  also  found  in  the  urine  in  small  quantities  after  in- 
haling chloroform  or  taking  chloral.  Among  the  insane,  sugar 
may  be  present  in  the  urine  without  there  being  other  symptoms 
of  diabetes,  and  without  grave  significance.!  Indeed,  this  ap- 
pearance of  sugar  in  the  urine  from  passing  causes  or  without 
other  marked  symptoms  has  given  rise  to  the  distinction  made  by 
some  between  glycosuria  and  diabetes,  restricting  the  latter  term  to 
a  persistent  glycosuria  with  decided  symptoms  and  most  likely 
with  a  lesion. jj 

In  some  instances  we  have  diabetes  with  coexisting  albuminuria, 
and  even  with  other  evidence  of  Bright's  disease.  In  the  majority 
of  such  instances  the  degeneration  of  the  kidneys  has  happened 
subsequently  to  the  diabetes,  and  in  its  more  advanced  stages  ;  but 

*  Med.-Chir.  Transactions,  1870,  and  Diseases  of  the  Kidney,  1875. 

f  Med.-Chir.  Transactions,  vol.  xxxviii. 

X  L'Union  Medicale,  No.  139,  1859.   . 

|  Lailler,  quoted  in  Journal  of  Mental  Science,  May,  1871. 

||  Lancereaux,  Bulletin  de  l'Acad.  de  Med.,  Nov.  1877. 


710  MEDICAL    DIAGNOSIS. 

I  have  met  with  eases  in  which  Bright's  disease  has  preceded  the 
diabetes. 

Chronic  Diuresis. — This  disease  is  otherwise  known  as  poly- 
uria, or  diabetes  insipidus.  It  is  characterized  by  the  habitual 
discharge  of  a  very  large  quantity  of  urine  containing  an  excess 
of  water,  but  no  sugar.  The  general  symptoms  are  much  the 
same  as  those  of  diabetes;  the  thirst  is  generally  extreme,  and,  if 
some  of  the  recorded  observations  can  be  fully  relied  on,  more 
water  is  passed  than  is  drunk. 

The  cause  of  this  singular  malady  is  obscure.  It  would  seem 
to  be  connected  with  some  abnormal  state  of  the  nervous  sys- 
tem. It  certainly  was  in  the  following  marked  instance  of  the 
affection  after  a  sunstroke  : 

A  young  man,  twenty-four  years  of  age,  was  admitted  a  number 
of  years  since  into  the  ward  I  then  had  at  the  Philadelphia  Hos- 
pital. He  was  thin,  greatly  troubled  with  thirst,  and  discharged 
daily  from  thirty-six  to  forty  pints  of  limpid  urine  of  a  very  low 
specific  gravity,  in  which,  by  several  tests  repeatedly  employed, 
not  a  trace  of  sugar  could  be  detected.  He  stated  that  he  had 
been  in  good  health  until  about  five  months  previously,  when  he 
had  a  sunstroke  while  laboring  on  a  building;.  He  was  for  a 
while  insensible,  and  from  that  time  had  had  constant  pain  in  the 
head,  and  had  been  unable  to  work.  He  lost  flesh  rapidly,  and  was 
much  annoyed  by  frequent  and  excessive  emission  of  urine.  Be- 
yond the  symptoms  mentioned,  little  was  found  in  the  case.  All 
the  internal  viscera  appeared  to  be  healthy;  the  bowels  were  con- 
stipated. 

The  patient  drank  an  enormous  amount  of  water,  though,  un- 
less he  obtained  the  coveted  liquid  by  stealth,  not  so  much  as  he 
habitually  passed.  For  upward  of  a  week  he  improved  on  tonics, 
especially  on  the  ignatia  amara,  voiding  once  only  seventeen  pints 
in  the  twenty-four  hours.  But  he  then  relapsed,  discharging  as 
much  water  as  before,  and  growing  daily  weaker  and  weaker. 
Suddenly  he  was  seized  with  very  great  irritability  of  the  stomach, 
and  complete  suppression  of  urine  ensued,  repeated  catheteriza- 
tions proving  the  bladder  to  be  empty.  He  was  cupped  over  the 
kidneys,  placed  in  a  warm  bath,  and  active  diuretics  were  ad- 
ministered, with  the  result  of  re-establishing  the  function  of  the 
kidneys.     But  the  diuresis  did  not  return ;  the  man  passed  about 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.     711 

a  pint  of  high-colored  fluid  daily  until  his  death,  which  took 
place  on  the  fifth  day  after  the  suppression  of  urine,  and  about 
six  months  after  the  sunstroke.  Toward  the  last  he  was  much 
troubled  with  uncontrollable  vomiting  and  obstinate  constipation, 
became  very  dull  and  stupid,  and  his  features  and  skin  assumed 
the  appearance  of  the  stage  of  collapse  in  cholera.  Permission  to 
examine  the  body  could  not  be  obtained. 

We  meet  with  cases  of  polyuria  also  under  other  circumstances, 
as  after  cerebro-spinal  fever,  or  in  connection  with  tumors  of  the 
brain,  or  with  disease  of  the  medulla  oblongata  or  of  part  of  the 
floor  of  the  fourth  ventricle,  or  with  tumors  compressing  the  ab- 
dominal ganglia.  Lancereaux  tells  us  that  the  disorder  is  not  un- 
common in  syphilitic  affections  of  the  nervous  centres.*  Again, 
I  have  repeatedly  encountered  the  malady  after  injuries  to  the  head,f 
or  in  persons  broken  down  with  malaria.  At  times  it  is  seen  in 
instances  simply  of  great  nervous  depression  without  organic  dis- 
ease. Recently,  it  has  been  stated  to.  coexist  with  excess  of  phos- 
phates, and  to  be  a  phosphaturia.  But  Senator  has  shown  that 
kreatinine  too  is  excreted  in  diabetes  insipidus  in  increased  quan- 
tity ;  indeed,  in  the  whole  amount  of  urine  passed  most  or  all  of 
the  solid  ingredients  are  found  in  rather  increased  quantity.^ 

We  must  take  care  not  to  confound  cases  of  chronic  polyuria 
with  true  diabetes.  They  differ  by  the  low  specific  gravity  of  the 
urine,  and  the  utter  absence  of  a  saccharine  ingredient.§  Some- 
times a  state  of  diuresis  is  found  to  exist  temporarily  during  the 
removal  of  dropsical  effusions,  or  when  the  action  of  the  skin  is 
insufficient.  We  also  meet  with  apparent  cases  of  diuresis  in 
hysterical  women  and  in  persons  who  suffer  from  incontinence  of 
urine,  whether  due  to  an  external  injury,  or  dependent  upon 
simple  irritability,  or  upon  inflammation  or  paralysis  of  the 
bladder.  In  all  such,  however,  we  can  establish  the  diagnosis  by 
laying  stress  on  the  history  of  the  patient,  and  by  measuring,  as 
accurately  as  possible,  the  amount  of  urine  passed  in  the  twenty- 

*  Sydenham  Society's  Transl.,  p.  76. 

f  Transactions  of  the  College  of  Physicians  of  Philadelphia,  1875. 

X  Blau,  in  a  comprehensive  article  in  Schmidt's  Jahrbucher,  NTo.  7,  1877. 

§  See,  on  the  examination  of  the  urine,  the  cases  collected  by  Parkes,  On 
the  Composition  of  the  Urine,  London,  1860;  and  Dickinson,  Diseases  of  the 
Kidney,  1875. 


712  MEDICAL    DIAGNOSIS. 

four  hours, — which  amount  may  be  large,  but  is  not  inordinate.    In 
some  instances  diabetes  mellitus  alternates  with  diabetes  insipidus. 

Disorders  in  which  little  or  no  Urine  is  discharged. 

Suppression  of  Urine. — Suppression  of  urine,  unconnected 
with  degeneration  of  the  kidney,  is  a  rare  disorder.  Yet  it  may 
occur  in  previously  healthy  persons,  or  in  the  course  of  fevers  of 
low  type,  and  probably  associated  with  no  other  morbid  state 
than  congestion  of  the  kidneys.  It  is  occasionally  met  with  as 
one  of  the  freaks  of  hysteria,  or  is  caused  seemingly  by  the  irri- 
tation reflected  to  a  healthy  kidney  from  a  diseased  bladder. 

The  symptoms  it  occasions,  independently  of  the  absence  of  the 
discharge  of  urine,  are  drowsiness,  nausea,  vomiting,  coma,  some- 
times convulsions;  in  one  word,  the  symptoms  of  ursemic  poison- 
ing. Irrespective  of  these,  as  Bourneville*  has  shown,  the  pulse 
and  temperature  both  sink  in  uraemia,  and  the  temperature  re- 
mains low  even  if  there  be  coexisting  internal  inflammations; 
and  the  formidable  complaint  may  give  rise  to  marked  urinous 
smell  of  the  perspiration  and  of  the  breath,  and  to  exceeding  and 
very  general  cutaneous  hypersesthesia.f 

Concerning  the  exact  cause  of  the  suppression,  we  are  often 
kept  in  the  dark  until  the  termination  of  the  malady;  for,  unless 
we  are  familiar  with  the  patient's  antecedent  symptoms,  we  are 
unable  to  determine,  in  the  absence  of  the  urinary  secretion, 
whether  or  not  a  disease  of  the  kidney  lies  at  the  origin  of  the 
mischief.  If  not  speedily  relieved,  the  affection  generally  ends 
in  death. 

In  accordance  with  the  observations  of  Oppolzer,  we  may  diag- 
nosticate thrombosis  of  the  renal  vein  if  we  have  diminution  of  the 
secretion  of  urine  and  its  final  suppression  preceded  by  blood, 
albumen,  and  casts  in  the  urine.     If  there  be  a  history  of  severe 

*  Gazette  Medicate  de  Paris,  1872. 

f  This  was,  next  to  the  suppression  of  the  discharge,  the  most  obvious 
symptom  in  a  case  under  my  care  in  1864  at  the  Philadelphia  Hospital,  in 
which  no  urine  was  secreted  for  many  days,  the  catheter  being  repeatedly 
introduced  into  the  bladder.  The  patient  recovered.  She  had,  previous  and 
subsequent  to  the  attack,  vesical  catarrh.  In  a  case  reported  by  Fuller,  St. 
George's  Hospital  Reports,  vol.  v.,  the  difficulty  existed  for  eight  days  with- 
out occasioning;  convulsions. 


THE  URINE  AND  DISEASES  OF  THE  URINARY  ORGANS.    713 

injury  to  the  kidney,  these  symptoms  have  a  much  more  positive 
meaning. 

Retention  of  Urine. — The  kidneys,  when  the  urine  is  simply 
retained,  perform  their  secretory  function,  but  the  fluid  collects  in 
the  bladder  and  is  not  voided.  The  distended  viscus  forms  a 
swelling  in  the  hypogastrium,  discoverable  both  by  palpation  and 
by  percussion.  The  urine  is  generally  not  wholly  kept  back,  for 
a  slight  discharge  every  now  and  then  takes  place,  or  there  is  a 
constant  dribbling, — a  matter  which  in  itself  should  suggest  the 
introduction  of  a  catheter. 

Retention  of  urine,  if  soon  recognized,  is  not  in  itself  a  dan- 
gerous complaint,  as  it  can  be  ordinarily  at  once  relieved  by  the 
passage  of  a  catheter;  but  if  the  ailment  escape  observation,  or 
be  inefficiently  dealt  with,  the  bladder  may  burst, — although  Sir 
Henry  Thompson  tells  us  that  this  is  a  circumstance  of  exceeding 
rarity, — or  the  patient  dies  from  the  absorption  of  the  noxious 
urinary  ingredients. 

The  causes  which  lead  to  retention  are  various ;  prominent 
among  them,  at  least  in  a  medical  point  of  view,  is  paralysis  of 
the  bladder,  especially  that  form  of  paralysis  which  occurs  in  low 
fevers ;  retention  is  also  one  of  the  symptoms  of  paraplegia ;  then 
inflammatory  swelling  of  the  neck  of  the  bladder,  organic  stric- 
ture, or  enlarged  prostate  may  give  rise  to  it ;  again,  retention  or 
incontinence  may  be  due  to  hysteria. 

The  disorder  is  readily  detected.  It  may  be  discriminated  from 
suppression  of  urine  by  the  existence  of  the  hypogastric  tumor, 
and  by  the  introduction  of  a  catheter, — a  means  which,  in  cases 
of  doubt,  ought  never  to  be  neglected.  Sometimes  the  abdominal 
swelling  is  so  great  as  to  lead  to  the  belief  of  the  existence  of 
dropsy ;  and  the  error  is  fostered  by  learning  that  the  patient  has 
been  passing  his  water  and  has  a  constant  desire  to  discharge  it, 
or  by  seeing  that  it  dribbles  from  him.*  But  I  have  already  dis- 
cussed these  points  in  connection  with  abdominal  swellings,  and 


*  In  a  case  reported  by  Schneider,  and  quoted  in  Brit,  and  For.  Med.-Chir. 
Eev.,  April,  1864,  urine  was  passed;  yet  when  a  catheter  was  introduced, 
because  the  peculiar  shape  of  the  tumefaction  seemed  to  indicate  that  the 
swelling  was  produced  by  a  distended  bladder,  fourteen  pints  of  urine,  and 
subsequently  eight  more,  were  removed. 


714  MEDICAL    DIAGNOSIS. 

need  only  here  again  draw  attention  to  the  errors  in  diagnosis 
which  are  likely  to  arise. 

The  retention  from  paralysis  is  distinguished  from  that  due  to 
other  causes,  as  obstruction,  by  observing  that  the  catheter  enters 
readily,  and  that  the  urine  flows  out  in  a  continuous  stream, 
increasing  and  lessening  with  the  respiratory  movements,  but  does 
not  come  out  in  jets, 


CHAPTER  VIII. 

DKOPSY. 

An  abnormal  collection  of  watery  fluid  in  the  areolar  tissue 
or  in  the  serous  cavities  of  the  body  constitutes  dropsy.  Now, 
dropsy  is  but  a  symptom,  and  as  such  we  have  already  examined 
into  it  as  associated  with  various  disorders  of  which  it  forms  a 
striking  manifestation ;  but,  though  only  a  symptom,  it  is  one  so 
obvious  and  prominent,  and  comprises  so  often  apparently  the 
whole  complaint,  that  it  will  serve  a  useful  purpose  to  investigate 
connectedly  the  clinical  meaning  of  its  typical  forms. 

Dropsy,  according  to  its  Seat  and  Extent. 

Dropsies  may  be  external,  or  confined  to  internal  parts.  To 
the  latter  variety  belong  hydro  thorax,  hydrocephalus,  and  ascites, 
— affections  elsewhere  described,  which  we  shall  consider  here 
only  so  far  as  they  may  form  part  of  a  general  dropsy. 

External  dropsies  are  illustrated  by  anasarca  and  cedema:  the 
first,  a  universal  accumulation  of  serous  fluid  in  the  areolar 
textures;  the  second,  a  more  localized  collection  in  the  same 
structures,  differing,  therefore,  in  nothing  but  extent.  Both, 
as  ordinarily  met  with,  exhibit  painless  swelling  of  the  surface, 
devoid  of  redness;  a  skin  often  stretched  and  shining,  pitting 
upon  pressure,  and  retaining  for  some  time  the  mark  of  the  finger ; 
and  in  both,  the  tumid  part,  if  punctured,  allows  a  watery  fluid 
to  run  out.  CEdema  is  most  commonly  perceived  around  the 
ankles ;  the  tumefaction  of  anasarca  is  found  generally  not  only 
in  the  lower  extremities,  but  also  in  the  arms  and  in  the  face. 

Anasarca  is  usually  dependent  upon  disease  of  the  kidneys,  or 
of  the  heart.  The  swelling  rarely  shows  itself  at  all  parts  of 
the  body  at  once :  it  ordinarily  begins  at  the  feet  and  ankles,  and 
extends,  more  or  less  rapidly,  upward ;  but  it  may  commence  in 
the  face.     It  is  greatest  where  the  areolar  tissue  is  loosest. 

715 


716  MEDICAL    DIAGNOSIS. 

(Edema  may  be  due  to  the  same  causes.  Yet  a  limited  collec- 
tion of  fluid  is  often  the  consequence  of  a  purely  local  difficulty 
unconnected  with  visceral  disease,  but  of  a  character  interfering 
with  the  venous  circulation.  Thus,  the  compression  or  oblitera- 
tion of  a  large  vein  occasions  oedema  below  the  point  of  the  dis- 
order. We  see  oedema  happening  if  a  bandage  be  applied  too 
tightly,  or  if  swollen  glands  press  upon  the  main  vein  of  a  limb. 
We  also  meet  with  it  in  the  adhesive  form  of  venous  inflamma- 
tion, and  in  milk-leg,  or  phlegmasia  dolens, — a  condition  observed 
in  puerperal  women,  or  as  a  sequel  of  typhoid  fever,  in  which 
the  whole  of  one  lower  extremity  becomes  oedematous,  in  conse- 
quence most  probably  of  the  blocking  up  of  the  femoral  vein  by  a 
coagulum.  In  all  of  these  forms  the  oedema  is  one-sided;  and, 
the  cause  being  external  to  the  thoracic  or  abdominal  cavities, 
there  is  little  difficulty  in  its  recognition.  A  circumscribed 
oedema  also  accompanies  erysipelatous  inflammations  of  the  skin 
or  subjacent  tissues;  so,  too,  do  we  find  oedema  confined  to  a  limb 
the  general  nutrition  of  which  has  been  lowered  by  paralysis. 

When  the  dropsical  effusion  is  dependent  upon  a  tumor 
seated  in  an  internal  cavity  and  interfering  with  the  passage  of 
the  blood,  it  may  be  very  local  and  one-sided,  as  we  sometimes 
find  in  connection  with  abdominal  cancer;  but  it  is  most  apt  to 
be  found  on  both  sides  of  a  portion  of  the  body,  although  more 
particularly  marked  on  one  side.  The  oedematous  extremities 
exhibit  usually  also  marked  enlargement  of  the  veins. 

Another  source  of  a  double-sided  oedema  is  a  watery  condition 
of  the  blood.  This  form  of  dropsy  is  often  seen  in  anaemia  with- 
out there  being  any  disease  of  an  internal  organ.  The  state  of 
the  blood  is  highly  favorable  to  the  transudation  of  the  serum, 
and  this  collects  first  about  the  ankles,  and  subsequently,  perhaps, 
in  other  parts  of  the  body.  The  absence  of  any  discoverable 
organic  affection,  the  pallid  countenance,  the  pearly  whiteness  of 
the  conjunctiva,  and  the  venous  murmurs  in  the  neck,  furnish  the 
key  to  the  recognition  of  the  origin  of  the  dropsy. 

A  dropsical  effusion  in  part  of  similar  origin,  but  much  more 
often  connected  with  internal  dropsy,  especially  with  ascites,  is 
the  dropsy  we  observe  in  those  broken  down  by  malarial  poison- 
ing. The  state  of  the  liver  and  spleen  added  to  the  condition  of 
the  blood  determines  the  greater  extent  of  the  effusion.     One  of 


DROPSY.  717 

the  most  extraordinary  forms  of  dropsy  connected  with  debility 
and  altered  blood  is  furnished  by  the  disease  known  to  the  phy- 
sicians in  India  as  beriberi,  in  which  the  anaemia  culminates  in 
acute  oedema  associated  with  stiffness  of  the  limbs,  numbness, 
extreme  prostration,  anxiety,  and  dyspncea.  General  anasarca, 
too,  and,  in  some  instances,  paralysis  of  the  extremities,  happen. 

Dropsy,  according  to  its  Causation, 

Having  viewed  anasarca  and  oedema  as  in  the  main  uncom- 
bined  with  internal  dropsies,  and  as  forming  the  sole  signs  of  the 
dropsical  complaint,  let  us  now  look  at  them  when  associated  with 
effusions  of  serum  elsewhere.  The  same  remarks  will  also  apply 
to  hydrothorax  and  ascites,  the  meaning  of  which,  when  occurring 
alone,  we  have  inquired  into,  but  which  we  shall  here  consider  in 
their  relations  to  general  dropsy,  or  that  form  of  the  disorder  in 
which  anasarca  or  oedema  coexists  with  dropsy  of  one  or  several  of 
the  large  serous  cavities. 

First,  let  us  examine  into  the  causes  of  general  dropsy.  The 
most  common  are  a  disease  of  the  heart,  of  the  kidneys,  or  of 
the  liver;  so  common,  in  truth,  that  in  every  case  of  dropsy  we 
must  always  examine  these  organs  carefully.  According  as  the 
dropsical  accumulation  originates  in  a  morbid  state  of  these  vis- 
cera, it  is  called  cardiac,  or  renal,  or  hepatic. 

Cardiac  dropsy  arises  in  consequence  of  the  deranged  or  en- 
feebled circulation  produced  by  a  disease  of  the  walls  and  cavities 
of  the  heart,  associated  or  not  with  a  valvular  lesion.  The  dropsy 
begins  in  the  feet  and  ankles,  being  much  influenced  by  position, 
and  gradually  extends  upward ;  but  it  is  rarely  very  obvious  in 
the  face  or  upper  extremities.  The  thighs  and  scrotum  are  some- 
times greatly  swollen,  and  there  is  a  watery  effusion  into  the 
pleural  cavities  or  into  the  pulmonary  parenchyma. 

Renal  dropsy  is  usually  much  more  general  than  cardiac  dropsy. 
It  does  not,  like  this,  begin  in  the  most  dependent  parts,  but  is 
often  first  noticed  in  the  face  and  eyelids.  There  is  hardly  a  space 
in  the  body  where,  as  the  complaint  progresses,  fluid  may  not  ac- 
cumulate. The  proof  that  the  dropsy  is  renal  is  furnished  by  the 
presence  of  albumen  in  the  urine,  and  by  the  other  signs  of  a  dis- 
eased kidney. 


718  MEDICAL    DIAGNOSIS. 

Occasionally  the  dropsy  is  owing  to  an  affection  of  both  the 
kidney  and  of  the  heart ;  then  the  inquiry  may  arise,  which  of 
the  organs  was  primarily  disturbed  and  gave  rise  to  the  dropsy  ? 
But  this  is  a  matter  we  cannot  more  than  indicate,  since  it  would 
involve  the  discussion  of  a  much-vexed  question,  namely,  whether, 
when  Bright's  disease  coexists  with  a  disease  of  the  heart,  the  renal 
affection  has  produced  the  cardiac  malady,  or  the  cardiac  malady  the 
renal  affection.  The  obvious  manifestations  of  the  latter  generally 
precede  the  former.  But  should  it  be  of  importance,  in  an  indi- 
vidual case,  to  determine  the  point  alluded  to,  we  may  be  enabled 
to  arrive  at  a  conclusion  by  a  close  examination  of  the  history  of 
the  case:  did  the  patient  suffer  from  palpitation  and  shortness  of 
breath  prior  to  or  coincident  with  the  anasarcous  condition,  and 
has  he  ever  had  rheumatic  fever;  or  did  he  have  an  attack  of 
acute  dropsy  before  the  persistent  swelling  of  the  feet  or  of  the 
face  occurred?  It  is  scarcely  necessary  to  add  that,  if  this  have 
happened,  there  is  a  strong  probability  of  the  renal  disease  having 
been  antecedent  to  the  cardiac  disorder. 

Hepatic  dropsy  may,  like  the  preceding  forms,  be  more  or  less 
general ;  but  it  is  very  rarely  so,  unless  it  be  of  long  standing,  or 
unless  there  be  coexisting  disease  of  the  heart  or  of  the  kidneys. 
The  most  usual  kind  of  dropsy  depending  upon  an  affection  of 
the  liver  is  abdominal  dropsy,  and  this  is  so  well  understood  that 
ascites  is  frequently  looked  upon  as  constituting  a  proof  of  hepatic 
disorder.  But  it  is  a  mistake  so  to  regard  it ;  for  ascites  may  also 
be  produced  by  peritoneal  tumors  or  inflammation,  by  enlargement 
of  the  spleen  or  of  the  pancreas,  or  by  the  pressure  of  diseased 
glands, — in  fact,  by  any  lesion  which  occasions  a  decided  impedi- 
ment to  the  portal  circulation. 

Again,  it  is  possible,  though  it  is  not  a  cause  which  acts  often, 
that  mere  irritation  of  the  areolar  tissue  will  occasion  more  or  less 
general  dropsy.  This  was  a  favorite  doctrine  of  the  older  physi- 
cians ;  and  a  recent  observer  thus  explains  the  dropsy  of  arsenical 
poisoning.* 

Besides  these  sources  of  general  dropsy,  we  may  find  deteriora- 
tion of  the  blood,  with,  perhaps,  a  simply  enfeebled  condition  of 
the  heart,  giving  rise  to  it.     But  such  a  state  is  much  more  likely 

*  H.  C.  Wood,  Jr.,  Amer.  Journ.  of  Med.  Sci.,  July,  1871. 


DROPSY.  719 

to  occasion  oedema,  or,  in  some  instances,  anasarca,  than  general 
dropsical  effusions;  and  it  is  thus  that,  while  the  former  phe- 
nomena are  not  uncommon  in  exhausting  diseases  or  in  marked 
impoverishment  of  the  blood,  the  latter  are  rarely  met  with  unless 
there  be  at  the  same  time  some  cardiac  or  renal  complaint. 

Dropsy,  according  to  the  Eapidity  of  its  Development. 

Dropsy  may  come  on  suddenly,  or  be  gradually  developed. 
The  first  is  called  acute  or  active  dropsy;  the  second,  chronic 
dropsy.  To  the  latter  class  belong  the  majority  of  instances  of 
the  forms  of  dropsy  just  discussed,  in  which  the  watery  accumula- 
tion is  thought  to  arise  from  defective  action  of  the  absorbent  ves- 
sels, or  in  which,  in  other  words,  the  dropsy  is  passive.  Acute 
dropsy  has  active  symptoms  much  like  those  of  an  inflammatory 
fever.  The  effusion  takes  place  suddenly,  and  in  consequence  of 
exposure  to  cold  and  wet,  or  of  a  checked  perspiration.  In  the  vast 
majority  of  examples  it  is  accompanied  by  albumen  in  the  urine, 
and  is,  in  truth,  due  to  a  disturbance  of  the  kidneys.  Yet  there  are 
cases  of  acute  dropsy  which  are  not  of  renal  origin,  and  in  which 
the  rapid  occurrence  of  universal  anasarca  is  not  susceptible  of 
being  traced  directly  to  a  definite  lesion. 

The  prognosis  of  dropsy  depends  upon  the  cause  of  the  effusion. 
The  least  dangerous  variety  of  the  complaint  is  that  happening  in 
connection  with  changes  in  the  blood.  The  acute  dropsies  are,  as 
a  rule,  much  more  curable  than  the  chronic  or  passive  forms  of 
the  disorder ;  but  their  prognosis  is  much  influenced  by  the  extent 
of  the  effusion  and  the  seat  it  may  occupy.  An  accumulation  of 
liquid  in  most  of  the  serous  cavities  of  the  body  is,  of  course, 
vastly  more  perilous  than  one  which  occupies  only  the  loose  sub- 
cutaneous tissues.  Local  dropsies  are  influenced  by  treatment  in 
proportion  to  the  readiness  with  which  the  obstruction  producing 
them  is  susceptible  of  being  removed. 


CHAPTER   IX. 

DISEASES    OF    THE    BLOOD. 

In  the  following  sketch  I  shall  attempt  to  describe  only  those 
disorders  of  the  blood  which  constitute  the  essential  or  principal 
forms  of  blood  disease,  which  are  seemingly,  for  the  most  part, 
idiopathic,  and  maybe  recognized  by  well-marked  clinical  traits. 
Prominent  among  these,  and  to  a  certain  extent  characteristic  of 
all  blood  disorders,  are  general  debility,  a  changed  aspect  of  the 
mucous  membranes  and  of  the  skin,  especially  in  color,  and  alter- 
ations of  nutrition. 

In  the  investigation  of  diseases  of  the  blood  the  microscope  is 
of  the  first  importance.  It  informs  us  with  regard  to  the  relative 
proportion  of  the  white  and  red  globules.  It  tells  us  something 
as  to  what  part  of  the  blood-making  organs  the  former  are  derived 
from  ;  it  indicates  whether  the  latter  are  of  proper  color,  whether 
their  outline  is  regular,  whether  they  form  rouleaux  properly,  and 
whether  their  number  is  decreased.  In  this  respect  recent  research 
has  aided  us  much  by  supplying  us  with  accurate  means  of  com- 
putation. 

The  method  of  determination  of  the  globular  richness  of  the 
blood  introduced  by  Vierordt,  in  1 854,  was  to  allow  a  stated  amount 
of  a  definite  dilution  of  the  blood  to  dry  upon  a  glass  slide,  and 
subsequently  by  the  aid  of  a  micrometer  to  count  the  number  of 
its  globules.  Imperfect  as  it  was,  by  it  he  ascertained  that  the 
normal  number  of  red  blood  corpuscles  in  a  healthy  male  adult 
was  between  five  and  six  millions  to  a  cubic  millimetre,  and  that 
in  certain  diseases  this  number  was  much  diminished.  Clinical 
observers  confirmed  these  observations,  and,  subsequent  improve- 
ments having  rendered  the  apparatus  more  precise,  systematized 
the  procedure  and  made  the  results  more  accurate.  The  forms  of 
apparatus  now  in  use  are  the  Compte-globule  of  Malassez,  the 
Hematimetre  of  Hayeni  and  Xachet,  and  the  Hsemacytorneter  of 
720 


DISEASES    OF    THE   BLOOD. 


721 


Fig.  50. 


Gowers ;  to  which  may  be  added  a  new  form  recently  introduced 
by  Mai assez,*  which  he  terms  his  Graduated  moist-chamber  Glob- 
ule-Counter (Compte-globules  d,  chambre  humide graduSe),  in  which 
some  of  the  advantages  of  the  other  methods,  proposed  since  the 
publication  of  his  original  paper  on  the  subject,t  are  adopted,  and 
every  care  is  taken  to  secure  the  nearest  possible 
approach  to  scientific  precision. 

By  the  original  method  of  Malassez  the  blood 
was  diluted  with  artificial  serum  so  that  it  repre- 
sented y^-Q-  or  -j^-jj  of  the  original.  A  small  amount 
was  then  introduced  into  a  flattened  capillary  tube 
of  known  capacity,  and  with  the  micrometer  eye- 
piece the  globules  were  counted  in  the  capillary 
tube  of  a  certain  length,  say  500  micro-millimetres. 
The  capacity  of  this  length  of  the  tube  in  parts  of 
a  cubic  millimetre  being  already  known,  the  entire 
number  of  globules  in  a  cubic  millimetre  of  the  un- 
diluted blood  was  easily  determined  by  calculation. 
For  the  purpose  of  diluting  the  bloodj  Potain's 
capillary  pipette  (Fig.  50)  is  well  adapted.  It  is  so 
constructed  as  to  contain  in  a  part  of  its  extent  a 
reservoir  imprisoning  a  glass  bead,  the  capacity  of 
this  chamber  being  exactly  one  hundred  times  that 
of  the  capillary  tube  leading  to  it.  To  the  opposite 
extremity  is  attached  a  rubber  tube,  which  being 
placed  between  the  lips  causes  the  fluid  to  ascend 
to  the  desired  extent  by  aspiration,  or  by  blowing 
through  it  the  tube  may  be  emptied. 

Hayem  and  Nachet  employ  an  ordinary  slide 
having  a  glass  ring  one-fifth  of  a  millimetre  in 
depth  cemented  upon  its  upper  surface.  A  drop 
of  diluted  blood,  but  not  enough  to  fill  the  cell,  is 
placed  in  the  middle  of  the  ring,  and  a  perfectly 
flat  cover  is  laid  carefully  upon  it.  Having  the  microscope  ad- 
justed as  before,  with  the  micrometer  eye-piece  the  number  of 


Potaiu's  pipette. 


*  Archives  de  Physiologie,  Xo.  8,  1880. 
f  Ibid.,  1874,  article  by  Malassez  and  Potain. 

X  Malassez  recommends  for  artificial  serum  a  5  or  6  per  cent,  solution  of 
sodium  sulphate,  having  sp.  gr.  of  1020  to  1024. 

46 


722  MEDICAL    DIAGNOSIS. 

red  blood  corpuscles  in  a  square  of  one-fifth  of  a  millimetre 
is  counted,  and  from  this  number,  which  represents  -3-^-3-  of  a 
cubic  millimetre  of  the  diluted  blood,  the  desired  amount  can  be 
determined. 

The  hemacytometer  of  Gowers  differs  from  the  preceding  in 
having  the  divisions  marked  on  the  bottom  of  the  cell,  in  squares 
each  one-tenth  of  a  millimetre  in  length.  The  other  parts  do  not 
vary  from  those  of  Hayem,  and  consist  of  a  pipette,  graduated  to 
995  cubic  millimetres,  for  measuring  the  diluting  solution;  a  capil- 
lary tube  for  measuring  the  blood  to  be  diluted,  and  containing  5 
cubic  millimetres,  to  which,  as  well  as  to  the  pipette,  for  conveni- 
ence' sake,  a  piece  of  elastic  tubing  is  attached;  a  small  glass  jar  in 
which  the  dilution  is  made  and  the  blood  and  solution  thoroughly 
mixed  by  a  small  spud;  and  the  cell  in  which  a  small  quantity  of 
the  dilution  is  placed  for  counting.  This  is  exactly  one-fifth  of  a 
millimetre  deep.  The  slide  bearing  the  cell  is  fixed  on  a  metal 
plate,  from  which  two  springs  project  on  to  the  edges  of  the  cell 
for  the  purpose  of  keeping  the  cover-glass  in  position  with  a  steady 
pressure.  When  in  use,  the  drop  of  dilution  placed  in  the  cell  is 
in  contact  with  the  cover-glass;  in  a  few  minutes  the  corpuscles 
sink  to  the  bottom  and  are  seen  lying  in  the  squares.  Each  square 
contains  the  corpuscles  from  a  volume  of  dilution  one-fifth  milli- 
metre in  one  dimension,  and  one-tenth  millimetre  in  each  of  the 
other  dimensions, — i.e.,  two  cubic  tenths  of  a  millimetre  (.002 
cubic  millimetre).  The  average  number  of  corpuscles  in  health 
being  fifty  in  this  space,  two  squares  should  contain  one  hundred. 
Gowers  therefore  proposes  to  take  the  contents  of  two  squares 
as  the  standard  volume,  and  to  term  it  the  hcemie  unit.  The  pro- 
portion as  compared  with  health  is  obtained  in  any  specimen  by 
counting  the  corpuscles  in  a  hsemic  unit,  or  counting  a  number 
of  such  areas,  such  as  ten  or  twenty,  and  taking  their  average 
as  the  true  expression.  In  health  one  cubic  millimetre  of  blood 
contains  about  five  millions  of  corpuscles. 

Malassez,  in  describing  his  new  Globule-Counter,  criticises  the 
hannic  unit  and  denies  that  such  a  proportion  as  it  expresses  bears 
any  absolute  relation  to  the  normal  globular  richness  of  the  blood, 
because  there  is  no  fixed  norm,  the  average  five  million  being 
only  a  mean  and  not  a  constant.  In  other  words,  the  number  of 
blood-cells  to  the  millimetre  cube  in  health  varies  in  different  in- 


DISEASES    OF   THE   BLOOD. 


723 


clividuals,  and  in  the  same  individual  in  certain  hours  in  the  day. 
The  gauge  adopted  by  Gowers  is  also  declared  to  be  too  large. 
Malassez,*  without  abandoning  his  original  design,  recommends 
an  improved  cell  for  microscopic  work,  which  he  has  recently  in- 
vented. It  consists  of  a  thick  glass  slide  having  ground  in  the 
centre  of  its  upper  surface  a  ring  or  circular  trench,  one  and  a 

Fig.  51. 


Graduated  moist-chamber  of  Malassez.    In  the  lower  figure  the  compressor  is  seen  attached  to  the 

slide. 

half  millimetres  in  breadth  and  one  millimetre  in  depth,  which 
leaves  a  plateau  of  about  seven  millimetres  in  diameter,  separated 
from  the  remnant  of  the  surface  of  the  slide  by  a  narrow  gutter, 
so  that  when  the  cover  is  in  place  water  may  be  placed  under  it  by 
capillary  attraction,  but  cannot  reach  the  islet  in  the  centre.  In 
this  way  any  fluid  may  be  protected  from  evaporation  while  under 
examination, — a  very  important  precaution  while  counting  blood- 
cells.  Outside  of  this  ring  three  or  four  holes  pierce  the  glass 
slide,  from  which  the  points  of  screws  are  made  to  project,  so  as 
exactly  to  maintain  the  cover-glass  at  one-fifth  of  a  millimetre 
above  the  surface.  A  micrometer  scale  is  engraved  upon  the  ob- 
ject-holder, which  obviates  the  necessity  of  regulating  the  micro- 
scope in  advance.  The  scale  on  the  object-holder  is  divided  into 
rectangular  spaces  one-fourth  of  a  millimetre  long  by  one-fifth 


*  Archives  de  Physiologie,  Juno,  1880. 


724 


MEDICAL    DIAGNn-l-. 


broad,  representing  each  one-twentieth  of  a  square  millimetre. 
Each  of  these  is  subdivided  into  twenty  little  blocks,  as  shown  in 
the  figure  (52),  each  one-twentieth  millimetre  square. 

In  order  that  the  cover-glass  shall  be  placed  quickly  and  exactly 
upon  the  screw-points  and  the  drop  of  diluted  blood,  the  cover  is 
attached  to  a  frame  moving  upon  a  hinge,  which  is  clamped  to  the 

Pig.  52. 


Blood-mixture  ;i>  seen  with  the  square  micrometer  ruling  of  the  moist-chamber  "t  Malassez;  mag- 
nified 250  diami  t    - 

slide.  The  glass  slide  is  kept  perfectly  horizontal,  and,  if  it  is 
feared  that  the  object  examined  will  dry,  a  little  water  or  the 
blood-mixture  may  be  dropped  upon  it,  so  as  to  surround  the 
circle  already  mentioned.  The  number  of  globules  contained  in 
twenty  of  the  little  squares  is  now  to  be  counted,  and  if  the  fluid 
used  be  a  centesimal  dilution  it  is  only  necessary  to  add  four 
ciphers  to  the  number  in  order  to  obtain  the  number  in  a  cubic 
millimetre,  since  the  large  squares  represent  the  ten-thousandth 
part  of  this  unit.  To  be  exact,  several  observations  should  be 
made.  The  greatest  care  is  required  after  each  enumeration,  in 
order  to  insure  cleanliness. 


DISEASES    OF    THE    BLOOD.  725 

The  blood  used  in  all  the  methods  referred  to  is  obtained  by  a 
sharp,  flat  needle  being  quickly  thrust  into  the  skin  near  the  root 
of  the  nail ;  the  finger  should  not  be  squeezed  or  have  a  ligature 
upon  it.  The  blood  is  then  drawn  into  the  capillary  tube  and 
measured.  The  advantages  of  this  method  in  determining  the 
presence  of  anaemia,  hydraemia,  or  true  plethora,  and  the  changes 
that  occur  in  leukaemia  and  similar  disorders,  are  obvious,  and 
have  been  well  considered  in  the  writings  of  Vierordt*  and  Welc- 
ker,f  Malassez  and  Potain,J  Thoma  and  Zeiss, §  Hayem  and 
]STachet,||  Gowers,^[  Cramer,  and  other  excellent  observers;  while 
the  effects  of  remedies  upon  the  globular  richness  of  the  blood 
have  been  especially  investigated  by  Bradford,  Cutler,  Keyes,** 
Amory,  and  Henry  and  INancrede.tt  Henry  and  Nancrede  insist 
that  not  only  the  results  but  also  the  details  must  be  published 
in  every  case,  or  else  they  are  apt  to  mislead,  and  as  a  result 
of  their  studies  they  conclude  that  accuracy  can  be  reached  only 
through  an  amount  of  labor  of  which  they  had  seen  no  detailed 
account. 

Anaemia, — This  is  the  name  given  by  Andral  to  poverty  of 
blood.  The  morbid  state  is  met  with  as  a  consequence  of  profuse 
or  frequently  recurring  hemorrhages,  of  insufficient  nourishment,  of 
affections  which  prevent  the  nutriment  taken  from  being  properly 
absorbed  or  assimilated,  thus  impoverishing  the  blood  by  de- 
priving it  of  its  most  needed  constituents,  and  of  profuse  chronic 
discharges,  which  drain  the  blood  of  many  of  its  important  ele- 
ments, and  especially  of  its  albumen.  Besides  these  causes  of 
anaemia,  we  find  it  occasioned  by  particular  poisons,  as  by  malaria, 
or  by  the  retention  of  noxious  ingredients  in  the  blood,  or  by 
diseases  of  certain  glands.     Again,  it  is  sometimes  encountered 

j : 

*  Archiv  fur  Physiolog.  Heilkunde,  1854. 

f  Yierteljahrsschrift  fur  die  Prakt.  Heilkunde,  18-54. 

X  Archives  de  Physiologie,  1874  ;  also  Societe  de  Biologie,  Seance  du  15 
Nov.  1879. 

g  Sitzungsberichte  der  Jenaische  Gesellschaft  fur  Med.  u.  Naturwissen. 
Jahrg.  1878. 

||  Gazette  Hebdomadaire  for  May  7,  1875  (with  bibliography) ;  also  Archives 
de  Physiologie,  1878,  p.  70U,  and  1879,  p.  208. 

T[  London  Lancet,  Dec.  1,  1877.     See  also  Practitioner,  July,  1878. 

**  American  Journal  of  the  Medical  Sciences,  Jan.  1876. 

ff  Boston  Medical  and  Surgical  Journal,  1879. 


726  MEDICAL    DIAGNOSIS. 

without  our  being  able  to  trace  it  to  any  obvious  source.  But 
under  all  these  circumstances  we  have  to  deal  with  a  watery 
blood  deficient  in  red  corpuscles;  in  other  words,  with  an  anaemic 
condition. 

Now,  whatever  may  have  given  rise  to  the  anaemia,  the  mani- 
festations of  the  disorder  are  much  the  same.  The  patient  is  weak 
and  pale;  his  lips  and  tongue  have  lost  their  red  color;  the  eye  is 
pearly;  his  pulse  is  feeble,  but  generally  accelerated;  the  appetite 
is  deficient  or  depraved;  the  bowels  are  apt  to  be  costive.  Exer- 
cise induces  great  fatigue,  shortness  of  breath,  and  palpitation; 
and  the  disturbance  of  the  heart  may  be  associated  with  cardiac 
murmurs  or  with  blowing  sounds  in  the  cervical  veins,  and  is 
sometimes  so  persistent  as  to  lead,  as  will  be  found  elsewhere  de- 
scribed, to  structural  changes  in  the  heart.  In  some  cases,  further, 
we  meet,  among  the  symptoms  of  the  affection,  with  obstinate 
headache  and  with  dropsy,  and  in  very  many  with  a  persistent 
pain  in  the  left  side,  in  the  region  of  the  spleen. 

Chlorosis. — Here  the  pallid,  waxlike  countenance,  the  very  pale 
lips,  and  the  pearly  eye  afford  unmistakable  evidence  of  the  dete- 
rioration of  the  blood,  consisting  chiefly  in  deficiency  of  haerno- 
globulin.  The  complaint  is  especially  encountered  in  young 
females,  and  is,  as  a  rule,  associated  with  amenorrhoea.  Indeed, 
many  restrict  the  term  to  the  obvious  anaemia  combined  with  sup- 
pression of  the  menses,  so  often  affecting  girls  about  the  age  of 
puberty.  In  pure  chlorosis,  organic  diseases  of  the  gastrointes- 
tinal apparatus,  of  the  spleen  and  lymphatic  glands,  or"  of  the 
lungs  and  kidneys,  are  absent ;  the  temperature  is  normal;  the 
nutrition  of  the  body  is  fairly  well  kept  up ;  the  nervous  system  is 
irritable.  Sometimes  these  symptoms  of  chlorosis  happen  before 
puberty;  or  there  are  relapses  of  the  malady  in  middle  age. 
Boys  about  the  age  of  puberty  may  also  develop  the  manifesta- 
tions of  chlorosis.  Virchow  has  pointed  out  the  frequent  asso- 
ciation of  chlorosis  with  narrowing  of  the  aorta  and  of  the  great 
arteries. 

Addison's  Disease. — There  is  another  form  of  anaemia  which 
requires  to  be  specially  mentioned,  namely,  that  connected  with 
disease  of  the  supra-i-enal  capsules.  Addison,  whose  name  the 
complaint  now  bears,  met  with  a  form  of  general  anaemia  which 
had  no  perceptible  cause  whatever;    in  which    there    had    been 


DISEASES    OF    THE   BLOOD.  727 

neither  loss  of  blood,  nor  mental  shock  or  anxiety,  nor  exhausting 
diarrhoea;  which  was  concomitant  with  neither  malignant  nor 
scrofulous  disease,  nor  with  any  affection  of  the  spleen,  kidneys, 
or  lymphatic  glands,  nor,  in  fact,  with  any  lesion  that  the  most 
careful  examination  could  detect. 

While  seeking  for  the  explanation  of  these  puzzling  cases,  he 
discovered  that  the  peculiar  anaemia  always  occurs  in  connection 
with  a  diseased  condition  of  the  supra-renal  capsules,  and  is  char- 
acterized by  distressing  languor  and  great  general  prostration, 
remarkable  feebleness  of  the  heart's  action,  loss  of  appetite,  obsti- 
nate vomiting,  and  a  singular  alteration  of  the  skin.  This  con- 
sists  in  a  dingy  or  smoky  hue  of  the  surface;  or  the  color  may 
be  of  a  deep  amber  or  chestnut  brown,  or  the  altered  skin  has  a 
bronzed  tinge.  The  change  of  color  begins  on  exposed  parts, 
such  as  the  face  and  neck  and  the  back  of  the  hands,  and  deepens 
first  there;  but  we  also  soon  find  it  marked  in  parts  which  are 
naturally  the  seat  of  much  pigment,  such  as  the  axillae,  the  groins, 
and  the  areola?  of  the  nipples.  It  is  also  marked  around  the 
umbilicus,  on  the  penis,  and  on  the  scrotum,  and  is  dependent  upon 
a  layer  of  pigment  in  the  rete  mucosum.  The  skin  remains  soft 
and  smooth,  and  becomes  in  large  portions  uniformly  discolored, 
gradually  deepening,  and  often  presenting  a  hue  on  the  face 
and  hands  like  that  of  a  mulatto.  Any  irritation  of  the  skin 
is  followed  by  dark  streaks.  Discoloration  in  patches  is  both 
less  constant  and  less  significant  than  extensive  alteration  of  hue; 
yet  the  darkening  in  undoubted  cases  may  occur  in  patches, 
which  are  usually  most  obvious  on  the  face  or  superior  extrem- 
ities. The  patient  may  seem  at  first  sight  to  be  jaundiced  ;  but 
the  pearly  whiteness  of  the  conjunctiva  soon  dispels  such  an 
idea.  The  nails  are  pale  and  bluish ;  the  tongue  may  have 
patches  of  dark  color;  the  body  and  breath  at  times  exhale  an 
offensive  odor ;  and  the  blood  has  been  found  to  contain  an  ex- 
cess of  white  corpuscles  and  a  slight  decrease  of  the  red,  although 
it  generally  does  not  undergo  any  important  or  characteristic 
change.* 

With  reference  to  the  other  symptoms,  the  most  conclusive  of 
them  are  remarkable  prostration,  generally  without  anv  marked 

*  Greenliow.  Addison's  Disease. 


728  MEDICAL    DIAGNOSIS. 

waste  of  the  body,  feebleness  of  heart's  action  and  of  pulse,  and 
obvious  anaemia.  In  most  cases,  but  far  from  in  all,  these  symp- 
toms precede  the  discoloration  of  the  skin  ;  and  they  are  not 
unfrequently  associated  with  pain  in  the  back  and  with  gastro- 
intestinal irritation,  with  breathlessness  upon  exertion,  with  ver- 
tigo, and  with  dimness  of  sight  or  impaired  hearing.  A  peculiar 
odor  of  the  body,  like  that  perceived  in  the  colored  race,  was 
observed  in  two  cases  placed  on  record  by  Mr.  Hutchinson.  In 
the  last  stages  of  the  malady  the  temperature  falls  below  the 
norm. 

Death  may  take  place  gradually  from  the  constantly  growing 
asthenia;  or  it  may  occur  suddenly,  and  where  the  amount  of 
prostration  does  not  appear  so  excessive  as  to  foreshadow  it.  The 
post-mortem  examination  shows  generally  the  organs  totally  de- 
stroyed. According  to  the  elaborate  researches  of  Wilks,  the 
destruction  is  dependent  upon  a  peculiar  scrofulous  degeneration ; 
while  Greenhow  states  it  to  be  due  to  an  inflammatory  exudation 
of  low  type.  Should  this  prove  to  be  the  correct  view  of  the 
case;  should,  in  other  words,  the  nature  of  the  disease  of  the 
capsules  influence  its  symptoms  more  than  the  mere  fact  of  their 
being  diseased,  it  would  explain  why  in  some  cases  of  absence  of 
the  gland,  or  of  its  cancerous  degeneration  or  suppuration,  no 
signs  of  Addison's  disease  existed.  It  would  then  be  a  specific 
disease  of  the  supra-renal  capsules  which  produces  the  manifesta- 
tions of  Addison's  disease.  Many  of  the  symptoms  of  the  fully- 
developed  malady  may  be  due  to  the  implication  of  the  nervous 
branches,  derived  from  the  sympathetic  and  pneumogastric,  which 
go  to  the  gland.  And  as  regards  all  the  symptoms,  it  must,  in  a 
diagnostic  point  of  view,  be  borne  in  mind  that  it  is  their  com- 
bination rather  than  the  presence  of  any  one  which  gives  them 
their  value,  and  that  this  combination  consists  chiefly  in  the  asso- 
ciation of  a  peculiar  discoloration  of  the  skin  with  a  pearly  eye, 
well-marked  anaemia,  and  prostration,  and  without  the  existence 
of  any  other  disease  than  of  the  supra-renal  capsules  to  account 
for  the  train  of  abnormal  phenomena.* 


*  See  the  cases  collected  by  Addison,  in  his  work  on  Diseases  of  the  Supra- 
renal Capsules ;  by  Wilks,  Guy's  Hospital  Reports,  vol.  viii.  and  vol.  xi.,  3d 
Series:  by  lLatley,  Brit,  and  Foreign  Medico-Chirurg.  Review,  18-38;  by 
Lay  cock,  ib.,  Jan.  1861;  by  Habershon,  Guy's  Hosp.  Rep., 3d  Series,  vol.  x.  ; 


DISEASES   OF   THE   BLOOD.  729 

Now,  in  the  diagnosis  of  Addison's  disease  the  alteration  of  the 
color  of  the  skin  plays  so  important  a  part  that  we  must  inquire 
whether  it  or  something  very  like  it  may  not  happen  in  other 
conditions.  In  persons  long  exposed  to  the  sun  a  bronzing  of  the 
face  and  neck  and  arms  occurs;  but  it  is  extremely  uniform; 
there  is  a  striking  contrast  between  it  and  the  parts  that  are  not 
exposed,  including  such  as  we  find  greatly  affected  in  Addison's 
disease,  the  flexures  of  the  joints,  the  scrotum,  the  textures  around 
the  nipple  and  the  umbilicus.  Moreover,  there  is  often  robust 
rather  than  impaired  health.  In  persons  who,  in  addition  to  ex- 
posure, are  of  uncleanly  habits  and  infested  with  vermin,  especially 
in  elderly  persons,  a  discoloration  of  the  skin  happens  at  various 
portions  of  the  body,  often  deepest  on  the  chest,  the  abdomen,  and 
the  back,  which  is  readily  mistaken  for  the  bronzing  of  Addison's 
disease.  But  in  this  vagrants'  disease  the  discoloration  is  in  the 
superficial,  not  in  the  deeper,  layers  of  the  epidermis,  and  the  dark 
cuticle  is  harsh  and  raised,  not  soft  and  smooth.  Then  alkaline 
baths  and  washing  with  soap  will  greatly  diminish  the  deepened 
hue. 

During  exhausting  lactation,  or  in  pregnancies  attended  with 
much  constitutional  disturbance,  there  may  be,  as  I  have  wit- 
nessed, marked  discoloration  of  the  skin ;  yet  it  is  not  most  obvious 
on  the  face,  and  the  circumstances  of  the  case  are  important  aids 
in  the  diagnosis.  So  is  the  history  in  those  instances  in  which  a 
bronze  hue  is  hereditary*  or  in  which  a  very  deceptive  discolor- 
ation follows  yellow  fever,  or  the  malarial  fevers,  or  chronic  dis- 
orders of  the  liver.  In  these  diseases,  too,  the  discoloration  is  not 
so  great,  and  it  is  not  marked  at  the  sites  most  affected  in  Addi- 
son's disease.  Greenhow  has  pointed  out  how  certain  very  long 
standing  instances  of  phthisis  exhibit  an  appearance  exactly  like 
that  of  the  earlier  stages  of  Addison's  disease.  Yet  the  abnormal 
pigmentation  does  not  deepen  or  increase,  and  the  symptoms  re- 
main only  those  of  the  pulmonary  malady.     Stains  on  the  skin 

hy  Copland,  in  Dictionary  of  Practical  Medicine ;  the  very  complete  report 
in  the  Transact,  of  Path.  Society  of  London,  1866 ;  the  excellent  account  hy 
Jaccoud  in  the  ISTouveau  Dictionnaire  de  Medecine ;  St.  Bartholomew's  Hos- 
pital Eeports,  vol.  vii.,  and  Greenhow's  Croonian  Lectures  on  Addison's 
Disease,  1875. 

*  Medical  Times  and  Gazette,  May,  1871. 


730  MEDICAL    DIAGNOSIS. 

from  pityriasis  versicolor  or  from  syphilis  have  not  the  character- 
istic seats  of  Addison's  disease,  and  they  are  in  patches  and  sur- 
rounded by  healthy  skin,  and  certainly  the  syphilitic  affection 
coexists  with  other  significant  eruptions  or  signs. 

One  of  the  most  difficult  questions  connected  with  the  diagnosis 
of  Addison's  disease  is  that  cases  occur  without  bronzing,  or  with 
the  color  of  the  skin  so  slightly  changed  as  to  be  a  matter  of 
doubt.  Such  cases  are  generally  in  persons  who  die  before  they 
have  had  the  disease  any  length  of  time.  If  the  altered  hue  of 
the  skin  be  wanting,  the  complaint  is  undistinguishable  from  per- 
nicious anaemia,  though  we  may  lay  some  stress  on  the  compara- 
tive absence  of  febrile  phenomena.  Other  diseases  of  the  supra- 
renal capsules,  such  as  cancer  and  waxy  disease,  are  also  not  to 
be  separated  from  the  peculiar  affection  of  the  gland  occasioning 
Addison's  disease,  if  bronzing  of  the  skin  be  not  present. 

The  malady,  as  Greenhow  proves,  is  very  rare  except  in  persons 
employed  in  manual  labor.  In  some  instances  it  seems  to  arise 
from  grief  or  protracted  anxiety.  The  disorder  is  a  chronic  one, 
generally  lasting  for  years;  but  it  almost  invariably  destroys  life. 
Yet  cases  have  been  recorded  in  which  most  of  the  symptoms  of 
Addison's  disease  existed  and  which  recovered;  and  certainly  long 
remissions  in  the  symptoms  have  been  not  infrequently  observed, 
and  in  these  remissions  the  discolored  skin  has  lightened. 

Pernicious  Anaemia. — This  is  a  fatal  form  of  anaemia,  well 
known,  at  least  in  some  of  its  varieties,  to  Addison,  which,  since 
the  recent  researches  of  Biermer,  has  activelv  engaged  the  atten- 
tion  of  the  medical  world.  It  is  an  extreme  anaemia  advancing 
steadily,  or  with  slight  remissions,  toward  a  fatal  ending ;  yet  no 
cause  can  be  detected  for  the  profound  and  disastrous  alteration 
the  blood  is  undergoing,  nor,  indeed,  can  any  adequate  cause  be 
discerned  for  its  origin.  To  pernicious  anaemia  belong,  therefore, 
most  of  the  cases  of  "essential"  or  "idiopathic  amernia"  which, 
since  the  time  of  Addison,  have  been  reported. 

The  disorder  is  most  frequent  in  women,  and  has  been  espe- 
cially observed  in  child-bearing  women  ;  still,  it  also  often  happens 
in  men,  especially  before  the  age  of  forty.  It  sometimes  seems 
to  have  its  origin  in  long-continued  dyspepsia  or  diarrhoea,  or 
to  arise  after  protracted  hemorrhages  or  incessant  worry, — after 
indeed  slowly  but  steadily-acting  debilitating  influences.     But  in 


DISEASES   OF    THE    BLOOD.  731 

the  majority  of  instances  it  originates  seemingly  without  cause, 
and  although  it  has  periods  of  deceptive  improvement  which  may 
last  for  months,  or,  as  I  have  known,  even  for  a  year,  it  progresses 
relentlessly  toward  a  fatal  issue.  It  is  true  that  very  recently 
some  cases  of  recovery  have  been  recorded  ;  but  of  these  it  is  not 
quite  certain  that  they  presented  all  the  well-marked  and  charac- 
teristic symptoms. 

What  are  these  characteristic  symptoms  ?  An  insidious  begin- 
ning for  the  obvious  anaemia,  except  at  times  when  this  develops 
itself  in  the  pregnant  state;  pale  tongue,  bloodless  lips,  pearly  eye, 
becoming  paler,  more  bloodless,  more  pearly,  from  week  to  week  ; 
breathlessness ;  palpitation  of  the  heart,  especially  on  exertion; 
weak  digestion  ;  constipation,  or  constipation  alternating  with  diar- 
rhoea ;  loud  systolic  murmurs  in  the  heart  and  venous  hum  in 
the  jugulars;  vertigo;  finally  extreme  exhaustion,  sluggishness  of 
mind,  fainting-fits,  and  dropsy,  without  persistent  albumen  in  the 
urine,  or  disease  of  the  liver,  or  enlargement  or  valvular  disease 
of  the  heart,  to  account  for  it.  In  the  later  stages,  too,  hemor- 
rhages from  the  nose  and  from  the  gums  are  not  uncommon  ;  and 
hemorrhages  from  the  uterus  or  from  the  kidneys,  or  into  the  skin 
and  into  the  retina,  may  also  be  noticed.  Yet,  notwithstanding 
all  these  grave  signs,  the  body  appears  well  nourished ;  there  is 
certainly  no  decided  emaciation,  except  in  instances  in  which  fever 
is  more  than  commonly  marked.  Xow,  fever  is  a  significant 
feature  of  progressive  pernicious  anaemia ;  it  has  been  present  in 
every  case  that  I  have  met  with.  It  is  not  an  early  symptom,  be- 
longing to  the  full  development  or  to  the  latter  part  of  the  dis- 
ease. It  is  of  very  irregular  type,  and  not  of  high  intensity,  the 
temperature  rarely  exceeding  103°  F.  It  is  apt  to  be  continued, 
or  to  show  occasional  exacerbations,  followed  by  remissions,  the 
febrile  state  lasting-  for  davs,  or  even  for  a  week  or  two  at  a  time  ; 
then  there  are  periods  of  shorter  or  longer  duration  when  it  wholly 
disappears,  to  come  on  again  in  an  outbreak  attended  with  all  the 
usual  signs  of  a  febrile  paroxysm  for  which  no  cause  is  apparent. 
Toward  the  end  of  the  case  it  is  not  unusual  for  the  anaemic  fever 
to  have  entirely  ceased,  and  for  the  temperature  to  have  fallen 
below  the  normal  standard. 

The  state  of  the  blood  in  this  perilous  malady  has  naturally 
been  made  a  subject  of  minute  investigation  :  there  is,  however, 


732  MEDICAL    DIAGNOSIS. 

nothing  that  is  really  distinctive.  The  reel  globules  are  pale  and 
strikingly  diminished  in  number  ;  the  white  corpuscles  are  not 
relatively  altered,  or  they  may  remain  normal,  and  seem  to  be 
increased,  because  the  red  globules  are  much  fewer.  The  shape 
<>f  these  was  stated  by  Eichhorst  to  be  characteristically  changed, 
in  so  far  at  least  that  the  blood  contains  a  quantity  of  ill-developed, 
small,  spherical  red  corpuscles.  But  these  are  not  pathognomonic; 
for  they  have  been  found  by  Cohnheim  in  medullary  leukaemia, 
by  Greenfield  in  lyniphadenoma,  by  Osier  in  the  blood  of  persons 
free  from  disease ;  and,  on  the  other  hand,  in  a  well-marked  in- 
stance of  pernicious  anaemia  examined  by  Bradbury*  they  were 
absent.  Nucleated  red  corpuscles  were  detected  in  the  blood  of 
all  the  patients  examined  by  Howard. f 

Of  the  real  cause  of  the  disease  we  are  in  ignorance.  No  con- 
stant lesion  of  the  blood-making  glands  has  been  found  to  ex- 
plain the  steady  and  destructive  impoverishment  of  the  blood. 
The  structure  of  the  spleen  and  of  the  lymphatic  glands  is  not 
altered ;  the  marrow  of  the  bones  may  or  may  not  be,  though  it 
was  markedly  so  in  a  case  reported  by  Pepper.!  Perhaps  the 
most  constant  lesion  is  fatty  degeneration  of  the  heart,  often  asso- 
ciated with  the  same  change  in  the  inner  coat  of  the  large  arteries. 

The  diagnosis  of  pernicious  anaemia  is  never  an  easy  one,  for 
the  reason  that  it  is  difficult  to  be  quite  certain  that  no  obscure 
and  latent  disease  exists  which  would  account  for  the  exhaustion 
and  the  progressive  alteration  of  the  blood.  Indeed,  it  is  only 
after  the  most  careful  and  repeated  examinations  of  all  the  organs 
of  the  body  and  the  most  searching  inquiry  into  the  history  of  the 
case  that  we  are  justified  in  making  the  diagnosis  of  pernicious 
anaemia.  I  have  more  than  once  known  ill-developed  organic 
disease  of  the  stomach,  especially  gastric  cancer,  where  the  tumor 
could  not  be  discerned,  or  contracted  kidney,  with  but  little  albu- 
men in  the  urine,  regarded  as  typical  illustrations  of  the  malady, 
until  the  autopsy  revealed  the  true  cause  of  the  fatal  exhaustion. 
With  reference  to  the  former  affection  the  error  is  all  the  more 
likely  to  happen  because  symptoms  of  gastric  disorder  are  not  un- 


*  British  Medical  Journal,  Aug.  14,  1880. 

t  Montreal  General  Hospital  Reports,  vol.  i.,  1880. 

j  American  Journal  of  the  Medical  Sciences,  Oct.  1875. 


DISEASES    OF   THE   BLOOD.  733 

usual  ill  progressive  anaemia ;  with  reference  to  disease  of  the 
kidney  the  misleading  part  is  that  a  trace  of  albumen  is  occa- 
sionally present  in  progressive  anaemia.  But  it  is  not  persistent ; 
and  microscopical  examination  of  the  urine  will  tell  us  the  real 
amount  of  kidney  affection. 

Diseases  of  the  heart  may  be  mistaken  for  pernicious  anaemia. 
An  ordinary  fatty  heart  in  an  elderly  person,  with  or  without 
valvular  disease,  with  failure  of  strength,  and  with  the  peculiar 
pallid,  sickly  look  occasioned  by  the  malady,  may  mislead.  But 
the  long  duration  of  such  cases,  the  gradual  growth  of  the  symp- 
toms, the  absence  of  fever,  are  strong  points  in  the  case.  Indeed, 
the  error  is  apt  to  be  the  other  way, — that,  overlooking  the  symp- 
toms of  profound  anaemia  and  general  failure,  we  regard  the  mur- 
murs and  the  other  cardiac  symptoms  which  are  associated  with 
the  fatty  heart  of  pernicious  anaemia  as  pointing  to  a  disease  of  the 
heart  alone.  The  physical  signs  will  not  always  assist:  the  mur- 
murs may  be  very  distinct  and  loud ;  in  fact,  a  recent  observer 
has  declared  that  they  are  due  to  a  true,  though  not  structural, 
insufficiency  of  the  mitral  or  the  tricuspid  valve.* 

If  we  have  excluded  any  organic  disease  that  could  account  for 
the  signs  of  exhaustion  and  of  anaemia,  we  turn  to  the  diseases  of 
the  blood  itself  to  obtain  an  explanation  of  the  symptoms.  And 
here  we  find  first  that  pernicious  anaemia  differs  from  ordinary 
ancemia  by  the  absence  of  the  history  of  the  causes  that  commonly 
give  rise  to  the  anaemic  state,  such  as  acute  diseases,  malaria,  tuber- 
cular or  cancerous  cachexia,  loss  of  blood,  and  the  like,  but  above 
all  by  its  relentless  course  and  the  little  influence  the  most  nour- 
ishing diet  and  courses  of  iron  have  on  it.  Moreover,  the  loud- 
ness of  the  cardiac  murmurs,  the  slight  emaciation,  and  the  ir- 
regular outbreaks  of  fever  are  very  significant.  The  outbreaks  of 
fever,  the  presence  of  dropsy,  though  moderate,  the  retinal  extrav- 
asations, the  other  hemorrhagic  symptoms,  and  the  unyielding 
blood-change,  separate  pernicious  anaemia  from  the  chlorosis  so 
common  at  the  age  of  puberty  in  young  girls,  and  generally  so 
readily  modified.  The  pernicious  malady  sometimes  seems  to 
develop  out  of  a  long-standing  chlorosis,  and  then  the  grave 
symjrtorns  just  alluded  to  tell  its  supervention.     The  same  grave 

*  Schepelern,  quoted  in  Schmidt's  Jahrbueher,  No.  4.  1880. 


734  MEDICAL    DIAGNOSIS. 

symptoms  happen  also,  at  least  the  hemorrhages  are  as  frequent, 
and  the  fever  and  dropsy  may  happen,  in  leukcemia  and  in  pseudo- 
Inih.vmia.  But  the  great  increase  in  the  white  corpuscles,  as  shown 
by  repeated  microscopical  examinations  of  the  blood,  the  tume- 
faction of  the  spleen,  or  the  affections  of  other  blood-making 
parts,  distinguish  the  former  malady;  and  pseudo-leuka?mia,  while 
the  blood  microscopically  will  not  differ  materially,  exhibits  the 
enlarged  lymphatic  glands,  their  progressive  invasion,  the  lym- 
phoid tumors,  the  abdominal  pains,  and  the  steadily-increasing 
emaciation  so  characteristic  of  the  disease. 

There  are  other  forms  of  idiopathic  anaemia  of  which  we  cannot 
clearly  recognize  the  cause,  that  we  shall  probably  soon  be  able  to 
separate  into  groups.  But  for  the  present  we  have  to  admit  that 
cases  may  happen  which  cannot  be  classified. 

Leukaemia. — This  morbid  state,  called  by  Virchow  leukae- 
mia, by  Bennett  leucocythaemia,  consists  in  a  decided  increase  of 
the  white  corpuscles  and  a  decrease  of  the  red.  Under  the  mi- 
croscope, which  furnishes  indeed  the  surest  means  of  recognizing 
the  disease,  the  white  globules  of  the  blood,  instead  of  bearing  the 
normal  proportion  of  about  1  to  50  of  the  red,  are  found  in  the 
proportion  of  1  to  6,  or  even  of  1  to  2  ;  and  after  death,  grayish 
coagula,  consisting  almost  entirely  of  colorless  blood-cells,  are  met 
with  in  the  heart  or  the  large  veins.  Besides  the  increase  of 
white  corpuscles  and  the  diminution  of  the  red,  peculiar,  colorless, 
shining,  elongated  octahedral  crystals  have  been  pointed  out  by 
Neumann. 

The  abnormal  condition  exists  in  connection  with  hypertrophy 
of  the  spleen  or  of  the  liver,  with  other  diseases  of  these  viscera, 
and  with  various  malignant  or  non-malignant  affections  of  the 
lymphatic  glands  or  of  the  thyroid  body,  especially  with  an  in- 
crease of  the  cellular  elements.  But  none  of  the  blood-glands  is 
so  constantly  and  so  markedly  affected  as  the  spleen.  It  has 
been  recently  stated  by  Xeumann  and  others  that  a  large  pro- 
duction of  lymphoid  cells  happens  in  the  marrow  of  the  bones, 
and  there  is  a  myelogenous  form  of  leukaemia ;  at  all  events  this 
happens  in  combination  with  the  other  forms. 

The  disorder  may  occur  at  all  ages,  and  in  both  sexes  ;  but  it 
is  more  common  in  men  than  in  women.  Leukaemia  is  conse- 
quent upon  obstinate  intermittents  with  decided  enlargement  of  the 


DISEASES    OF    THE   BLOOD.  735 

spleen,  syphilis,  over-exertion,  long-continued  mental  depression, 
chronic  intestinal  catarrh,  and  blows  on  the  splenic  region.  The 
form  affecting  the  marrow  of  the  bones  frequently  results  from  in- 
jury to  the  bones.  But  in  many  cases  of  leukaemia  no  adequate 
cause  can  be  detected.  Its  beginning  is  usually  gradual  and  ill 
defined ;  sometimes  it  clearly  follows  other  diseases.  When 
fully  developed,  it  often  occasions,  besides  the  obvious  pallor  and 
the  cachectic  appearance,  exhaustion,  diarrhoea,  extremely  hurried 
breathing,  hemorrhages  from  various  parts,  especially  from  the 
nose,  profuse  sweating,  slight  rise  of  temperature  in  the  evening, 
increase  of  uric  acid  in  the  urine,  fleeting  abdominal  pains,  and 
dropsy  dependent  upon  the  enlargement  of  the  spleen  or  of  the 
liver  or  upon  the  leukemic  new  formations  in  the  latter.  In  some 
cases  a  swelling  of  the  glands  on  both  sides  of  the  throat,  attended 
with  inflammation  of  the  mucous  membrane  of  the  mouth  and  the 
pharynx,  and  followed  by  swelling  of  the  axillary  and  the  inguinal 
glands,  precedes  the  enlargement  of  the  liver  and  the  spleen.* 

Indeed,  glandular  tumors  are  often  present;  the  glands  of  the 
groin  are,  as  a  rule,  enlarged.  There  is  disturbance  of  vision, 
connected  with  retinal  changes,  also  melancholy,  and  in  some  in- 
stances deafness,  and  peritoneal  or  pleural  inflammations.  Pain 
in  the  bones,  too,  particularly  in  the  sternum,  is  observed.  The 
medullary  or  myelogenous  variety  is  especially  marked  by  pain, 
which  is  increased  or  developed  by  pressure  over  the  sternum 
and  ribs  and  over  other  affected  bones.f 

The  diagnosis  of  leukaemia  is  only  possible  by  the  microscopical 
examination  of  the  blood,  which  detects  the  decided  increase  of 
the  white  corpuscles.  In  the  most  common  variety,  splenic  leu- 
kaemia, we  may  also  be  able  even  early  to  discern  the  enlargement 
of  the  spleen,  and  find  the  evidences  of  a  cachexia  in  the  look  of 
the  patient,  and  in  recurring  epistaxis.  But  it  is  the  microscopical 
examination  of  the  blood  alone  which  enables  us  to  distinguish 
leuksemic  swelling  of  the  spleen  from  its  other  affections.  And 
to  have  a  definite  diagnostic  meaning  the  white  corpuscles  must 
be  decidedly  and  permanently  increased ;  for  a  mere  transitory, 


*  Mosler,  in  Virchow's  Archiv,  xliii. 

t  Mosler,  Berlin.  Klin.  "Wochenschr.,  xiii.,  1876;  and  Schmidt's  Jahrbucher, 
No.  10,  1877. 


736  MEDICAL    DIAGNOSIS. 

slight  increase  may  occur  in  other  diseases  of  the  spleen.  Some 
corpuscles  are  larger,  some  smaller,  than  normal,  and  many  show 
fatty  changes.  Lymphatic  leukaemia  is  chiefly  recognized  by  the 
marked  swelling  of  the  lymphatic  glands,  while  the  spleen  is  less 
obviously  affected.  In  the  blood  the  white  corpuscles  derived  from 
the  lymphatic  glands  are  said  to  be  smaller  than  those  coming 
from  the  spleen,  and  to  have  a  well-developed  nucleus.  But  it  is 
very  difficult  to  judge  a  case  by  these  traits.  Large  round  cor- 
puscles containing  granules  which  by  ether  and  chloroform  are 
found  to  be  fatty  are  stated  to  be  derived  from  the  marrow  of  the 
bones,  and,  if  abundant,  to  bespeak  medullary  leukaemia.* 

Pseudo-leukcemia* — As  regards  the  symptoms,  the  closest  simi- 
larity to  leukaemia  is  presented  by  the  affection  described  as 
pseudo-leukaemia,  lymphadenoma,  or  Hodgkin's  disease.  It  con- 
sists in  an  enlargement  of  the  lymphatic  glands  of  the  body, 
often  with  lymphoid  growths  in  other  parts,  which  soon  becomes 
complicated  with  extreme  anaemia,  with  weakness  and  signs  of 
cachexia,  with  diarrhoea,  with  dropsy,  with  cardiac  palpitation, 
shortness  of  breath,  and  attacks  of  suffocation,  with  tendency  to 
profuse  bleedings  and  to  bed-sores,  and  leads  usually,  in  the  course 
of  not  many  months,  or,  at  farthest,  of  a  few  years,  to  death. 
There  is  often  a  sense  of  fulness  in  the  abdomen,  attended  with 
violent  pains;  the  temperature  in  advanced  cases  shows  mostly 
an  evening  rise.  Some  of  the  superficial  lymphatics  are  first  af- 
fected, others  follow;  the  disorder  then  extends  more  decidedly, 
the  spleen  and  the  liver  increase  in  size,  other  organs,  too,  may 
become  involved,  and  lymphoid  tumors  develop  in  various  parts 
of  the  body ;  but  among  the  internal  organs  the  spleen  is  the  one 
most  constantly  disturbed. 

The  disease  generally  begins  in  the  cervical  glands;  far  less 
frequently  does  it  show  itself  first  in  the  inguinal  or  in  the  axil- 
lary glands;  still  less  frequently  in  the  bronchial  or  in  other  in- 
ternal glands.  The  affection  occurs  much  oftener  in  men  than  in 
women.  It  mostly  happens  between  the  ages  of  ten  and  thirty- 
five  and  of  fifty  and  sixty,  but  is  not  very  uncommon  in  young 
children.  Its  cause  is  unknown;  it  certainly  has  no  definite  con- 
nection with  either  scrofula  or  syphilis. 

*  Schmidt'.-  Jahrbiicher,  No.  10,  1877. 


DISEASES   OF   THE   BLOOD.  737 

The  chief  anatomical  lesion  is  found  to  be  an  augmented 
formation  of  the  structure  of  the  glands.*  The  spleen  is  either 
simply  hypertrophied,  or  is  the  seat  of  numerous  disseminated 
lymphoid  growths ;  in  neither  case  is  it  apt  to  attain  to  any  very 
great  size.  At  times  the  follicles  at  the  base  of  the  tongue,  in  the 
tonsils,  and  in  the  intestines  share  in  the  morbid  process;  changes 
in  the  bone-marrow  are  rare.  The  blood  shows  deficiency  in  red 
globules,  but  otherwise  no  constant  alteration.  Slight  increase 
of  leucocytes  has  been  occasionally  noticed,  especially  during  the 
later  stages ;  but  even  then  the  white  corpuscles  are  small. 

It  is  this  difference  in  the  state  of  the  blood  that  makes  the 
chief  difference  between  pseudo-leukaemia  and  leukcemia,  in  which 
there  may  be  glandular  enlargements.  Further,  leukaemia  is  a 
disease,  as  a  rule,  of  longer  duration,  and  the  splenic  enlargement 
is  generally  much  more  marked.  Rare  cases  of  diffused  lymphatic 
cancer  closely  resemble  Hodgkin's  disease;  so  closely  that  they 
are  undistinguishable,  except  by  the  history  of  the  case  and  by  a 
microscopical  examination  of  any  of  the  tumors  that  may  have 
been  removed ;  the  spleen,  too,  is  not  apt  to  be  involved,  while 
the  organs  contiguous  to  the  glandular  cancer  are  likely  to  be 
more  rapidly  implicated.  In  sarcoma  of  the  lymphatic  glands  the 
disease  is  at  first  strictly  local,  and  then,  if  it  spread,  invades  not 
the  lymphatic  tissues  specially,  but  any  part  of  the  body.  Local 
gland  lymphomas  are  separated  from  Hodgkin's  disease  by  their 
local  character,  by  their  want  of  extension,  and  by  the  absence 
of  marked  cachexia.  Scrofulous  glands,  unlike  lymphadenoma, 
enlarge  rapidly,  have  thickened  tissue  around  them,  and  are  apt  to 
undergo  cheesy  degeneration,  or  to  soften  and  suppurate.  More- 
over, they  are  associated  with  the  general  evidences  of  scrofula. 

In  the  early  stages  of  pseudo-leukaemia  a  diagnosis  is  impossible, 
and  we  are  at  a  loss  to  account  for  the  increasing  signs  of  cachexia, 


*  See  the  cases  of  Hodgkin,  Med.-Chir.  Trans.,  vol.  xviii.;  of  Wilks,  Guy's 
Hospital  Eeports,  vol.  xi.,  3d  Series;  of  Black,  Amer.  Journ.  of  Med.  Sci., 
April,  1866 ;  of  Wunderlich,  Archiv  der  Heilkunde,  1866 ;  and  a  review  by 
Spillman,  Arch.  Gen.,  1867,  vol.  ii. ;  Trousseau's  Lecture  on  Adenia,  in  his 
Clinical  Medicine ;  Langhans,  Virchow's  Archiv,  Bd.  liv. ;  James  H.  Hutchin- 
son, Transactions  of  the  Philadelphia  College  of  Physicians,  3d  Series,  vol.  i. ; 
Haward,  London  Clinical  Society's  Transactions,  vol.  ix. ;  Gowers,  Eeynolds's 
System  of  Medicine,  vol.  v.,  1879. 

47 


738  MEDICAL   DIAGNOSIS. 

until  the  involvement  of  the  lymphatic  glands  in  rapid  succession, 
and  their  quick  growth,  or  the  speedy  formation  of  other  lymph- 
oid tumors  under  the  skin  or  in  other  parts  of  the  body,  clears 
up  all  doubt.  There  will  also  be  great  uncertainty  in  all  those 
instances  in  -which  the  growths  happen  first  in  internal  glands  or 
structures, — as  in  the  bronchial  glands  and  the  mediastinum,  pro- 
ducing severe  bronchitis,  extreme  dyspnoea,  and  signs  of  venous 
stagnation  in  the  veins  of  the  upper  part  of  the  body ;  or  as  in 
the  glands  around  the  biliary  ducts,  giving  rise  to  jaundice;  or 
as  in  growths  in  the  spinal  cord  leading  to  paraplegia, — until  the 
external  swellings  explain  the  case.  The  kidney  is  not  an  organ 
that  often  suffers  primarily;  the  occurrence  of  more  than  a  mere 
trace  of  albumen  shows  that  it  has  become  implicated  from  paren- 
chymatous changes  or  disseminated  lymphoid  growths. 

Pyaemia. — Purulent  contamination  of  the  blood  is  an  affec- 
tion much  more  apt  to  be  met  with  by  the  surgeon  than  by  the 
physician ;  yet  it  is  one  sufficiently  often  encountered  by  him  to 
require  that  he  should  be  familiar  with  its  symptoms.  These  are, 
great  depression  of  the  vital  powers,  profuse  sweats,  rapid  pulse, 
and  the  formation  of  purulent  deposits  in  different  portions  of 
the  body.  The  symptoms  may  be  of  gradual  development ;  but 
often  they  set  in  suddenly  with  a  chill,  to  which  a  fever  of  low 
type  soon  succeeds;  or  the  shivering  is  followed  even  from  the 
first  by  copious  sweating,  and  the  febrile  phenomena  subsequently 
appear. 

The  pya?mic  fever  rarely  lasts  longer  than  a  week,  and  during 
its  continuance  it  usually  presents  the  most  marked  variations  in 
temperature.  Yet  the  disease  is  not  always  alike  in  this  respect; 
for  we  find,  as  Heubner  has  proved,  not  only  cases  in  which  the 
most  decided  increase  of  heat  is  constantly  followed  by  an  equally 
decided  decrease,  but  also  cases  in  which  there  are  febrile  attacks, 
followed  by  marked  intervals,  during  which  the  temperature  is 
almost  normal ;  and  cases  in  which  continuous  fever  exists  with 
striking  intercurrent  rises  in  temperature.*  Still,  in  all  the  maxi- 
mum temperature  is  apt  to  be  very  high,  ranging  from  106° 
to  108°. 

The  disorder  may  arise  after  injuries  and  operations ;  or  where 

*  Archiv  der  Heilkunde.  ix.,  1868. 


DISEASES    OF   THE   BLOOD.  739 

sinuses  or  abscesses  exist  that  have  no  free  vent  for  the  pus ;  or  in 
consequence  of  the  contamination  of  the  blood  which  happens  in 
phlebitis  or  arteritis;  or  in  inflammation  of  the  external  coat  of 
arteries,  with  suppuration,  especially  in  the  periarteritis  of  the 
thoracic  aorta;  or  in  ulcerative  endocarditis;  or  the  pyaemia  re- 
sults from  the  breaking  down  of  coagula  which  have  formed  in 
the  blood-vessels;  or  it  may  supervene  upon  diffuse  cellular  in- 
flammations, or  upon  puerperal  fever:  in  fact,  it  will  be  found 
under  many  dissimilar  circumstances.  But,  without  stopping  to 
explain  its  varying  sources  of  origin,  let  us  look  at  its  diagnostic 
traits. 

Now,  there  are  several  complaints  with  which  pyaemia  is  likely 
to  be  confounded,  the  chief  of  which  are  typhoid  fever,  rheuma- 
tism, acute  glanders  and  farcy,  and  acute  affections  of  the  liver. 

It  is  liable  to  be  mistaken  for  typhoid  fever,  on  account  of  the 
adynamic  character  of  the  fever,  and,  it  may  be,  the  occurrence 
of  diarrhoea  and  of  cerebral  symptoms.  But  the  history  of  the 
case  is  very  dissimilar :  there  is  no  eruption,  or,  if  there  be  an 
eruption,  it  consists,  as  Bristowe  so  particularly  points  out,  of 
sudamina  surrounded  by  a  zone  of  congestion,  and  is  therefore 
not  the  eruption  of  the  typh-fevers ;  and,  on  the  other  hand,  we 
find  in  typhoid  fever  neither  the  profuse  sweating  nor  secondary 
deposits  of  pus,  and  the  thermometry  of  the  disease  is  very  differ- 
ent. We  must  not  forget,  however,  that  pyaemia  may  happen  as 
a  complication  of  the  febrile  malady. 

The  pain  in  the  joints  and  their  swelling  in  succession,  the 
fever,  and  the  perspirations,  resemble  much  at  times  rheumatic 
fever.  But  the  difference  consists  in  the  greater  severity  of  the 
constitutional  phenomena  caused  by  the  poisoned  blood,  in  the 
marked  exhaustion,  in  the  rigors,  and  in  the  history  not  being  that 
of  acute  rheumatism.  Moreover,  the  frequent  signs  of  formation 
of  abscesses  in  internal  organs  or  around  the  joints,  the  develop- 
ment of  pustules  on  the  skin,  and  the  striking  redness  of  the  tumid 
joints  assist  materially  in  the  diagnosis. 

Acute  glanders  or  acute  farcy  is  a  disease  scarcely  distinguish- 
able from  pyaemia,  since  it  occasions,  for  the  most  part,  the  same 
manifestations.  The  knowledge  that  the  patient  who  has  ap- 
parently pyaemic  symptoms  has  been  working  among  horses,  the 
ulceration  of  the  mucous  membrane  of  the  nose,  and  the  fetid 


740  MEDICAL    DIAGNOSIS. 

discharge  proceeding  from  it,  which  occurs  in  acute  glanders,  and 
which  is  apt  to  be  associated  with  nasal  hemorrhages,  with  an 
offensive  breath,  with  enlargement  of  the  lymphatic  glands  in 
the  vicinity  of  the  affected  mucous  membrane,  and  with  hurried 
breathing,  or  sometimes  with  gangrene  of  various  parts, — afford 
us  the  only  means  of  discrimination.  Then  we  find  a  peculiar 
tuberculated  or  pustular  eruption  which  appears  upon  the  skin, 
and  in  farcy  the  lymphatic  glands  and  vessels  specially  suffer. 
But  more  significant  than  all,  in  point  of  diagnosis,  is  being 
able  to  trace  the  distinct  history  of  the  contagion  ;  for  the  grave 
coryza  and  some  of  the  other  prominent  symptoms  mentioned  do 
not  happen  in  all  forms  of  equinia, — certainly  not,  at  least  it  is 
generally  so  stated,  in  farcy. 

Acute  affections  of  the  liver  resemble  pyaemia  on  account  of  the 
jaundice  which  may  attend  the  latter  disorder;  but  the  history 
of  the  case,  the  rigors,  the  sweats,  and  the  purulent  deposits,  dis- 
tinguish it.  But  it  must  be  remembered  that  metastatic  abscesses 
of  the  liver  happen. 

In  conclusion,  let  us  inquire  where  and  how  the  secondary  de- 
posits are  formed.  They  may  take  place  in  the  parenchymatous 
organs,  particularly  in  the  lungs  and  liver;  in  the  synovial  sacs, 
in  muscles,  or  in  areolar  tissue,  especially  in  that  under  the  skin. 
To  account  for  their  formation  the  view  now  most  generally  ac- 
credited is  that  the  vitiated  blood  coagulates  in  either  the  veins, 
heart,  or  arteries,  usually  in  the  former,  and  that  the  clots,  be- 
coming disintegrated,  are  washed  into  the  smaller  vessels  or  capil- 
laries of  individual  tissues,  and  there  give  rise  to  inflammation 
and  the  development  of  pus.  There  may  be  capillary  embolism 
in  pyaemia,  not  to  be  recognized  except  by  the  microscope.* 

It  has  just  been  indicated  that  the  altered  blood  may  coagulate 
in  the  arteries.  Xow,  when,  from  this  cause,  or  from  disintegra- 
tion of  fibrin  in  the  arterial  system,  the  fibrinous  masses  occasion 
deposits  in  solid  organs,  as  in  the  liver  or  the  spleen,  we  may  have, 
with  the  similar  pathological  states,  similar  symptoms  arising  to 
those  of  true  pyaemia.  Indeed,  in  the  arterial  jjycemia,  as  it  has 
been  called,  rigors,  febrile  symptoms  and  sweating,  and  pains  in 
the  joints  are  observable.     In  connection  with  the  obscure  febrile 

*  Hayem,  quoted  in  Half-Yearly  Abstract,  Jan.  1872. 


DISEASES    OF   THE    BLOOD.  741 

condition,  the  liver  and  the  spleen  are  often  observed  to  increase 
in  size  slowly.*     The  heart  may  or  may  not  be  affected. 

There  is  a  form  of  pyaemia,  or,  as  Leube,f  who  has  so  well 
described  it,  calls  it,  spontaneous  septico-pya?mia,  which  comes  on 
without  obvious  cause,  or  is  perhaps  preceded  by  a  fall  or  a  slight 
skin-wound,  in  which  the  symptoms  of  pyaemia  become  developed 
with  pain  and  tenderness  in  joints  and  muscles,  ecchymosis  of  the 
conjunctiva,  vesicles  in  the  skin  containing  blood,  extremely  high 
temperature,  swelling  of  the  spleen,  albuminous  urine,  pleurisy 
or  perhaps  signs  of  endocarditis  or  pericarditis,  stupor,  delirium, 
cramps,  and  finally  involuntary  discharges  and  coma.  The  dis- 
ease, resembling  typhus  or  ulcerative  endocarditis,  is  to  be  dis- 
tinguished only  by  the  general  association  of  the  symptoms. 

The  description  of  pyaemia  given  represents  it  as  an  acute  affec- 
tion, and  so  it  almost  always  is.  Yet  there  are  cases  much  slower 
in  their  course,  and  extending  over  months.  These  chronie  or 
relapsing  instances  of  the  disease  have  been  described  by  Sir 
James  Paget,!  in  his  usual  concise  and  happy  manner.  The 
symptoms  presented  are  the  same  as  in  the  acute  disorder;  but  the 
local  evidences  of  the  complaint  are  more  often  seated  in  different 
parts  of  the  same  tissues,  and  less  frequently  in.  internal  organs. 
The  malady  is  not  nearly  so  perilous  as  the  acute  disease. 

Septicaemia. — This  is  a  poisoned  state  of  the  blood,  produced 
by  mineral  and  vegetable,  but  especially  by  animal,  poisons,  such 
as  the  bites  of  venomous  serpents  or  the  absorption  of  putrid 
matters  which  have  been  generated  in  the  economy,  or  by  their 
inoculation.  The  continued  exposure  to  the  breathing  of  foul  air 
and  of  septic  gases  will  also  occasion  septicaemia.  The  symptoms 
of  the  blood-poisoning  vary  somewhat  with  the  individual  poison 
that  has  occasioned  it.  They  are,  in  the  main,  the  symptoms  of 
pyaemia,  except  that  secondary  pus  formations  belong  to  the  former 
rather  than  to  the  latter ;  and  the  same,  of  course,  may  be  said  of 
embolism  and  its  results.  Rigors  are  frequently  observed.  In 
many  instances  the  altered  condition  of  the  blood  leads  to  hemor- 
rhages from  internal  organs,  to  petechia,  to  delirium  and  coma,  to 


*  Samuel  Wilks,  Guy's  Hospital  Eeports,  vol.  xv.,  3d  Series. 

f  Archiv  fur  Klin.  Med.,  xxii.,  1878. 

%  St.  Bartholomew's  Hospital  Eeports,  vol.  i. 


742  MEDICAL    DIAGNOSIS. 

extreme  rapidity  of  pulse,  to  high  temperature  with  burning  heat 
of  skin,  to  enlargement  of  the  spleen,  to  cough  and  bronchial 
catarrh,  and  to  gastric  and  intestinal  disorders.  The  blood  mi- 
nutely examined  shows  the  white  corpuscles  almost  always  greatly 
in  excess,  although  not  altered  in  character  as  they  are  apt  to  be 
in  leukaemia ;  the  red  globules  are  diminished.* 

Thrombosis  and  Embolism. — While  discussing  endocar- 
ditis, the  phenomena  of  embolism  have  been  alluded  to,  and 
they  have  also  been  mentioned  in  connection  with  several  other 
subjects,  as  of  obstruction  of  the  cerebral  arteries,  and  of  some 
diseases  of  the  kidney.  Yet  it  may  serve  a  useful  purpose  to 
view  here  connectedly,  though  chiefly  in  their  diagnostic  bearing, 
some  of  the  results  of  the  formation  of  the  clots  in  large  vessels 
or  in  the  heart,  and  of  their  being  carried  along  with  the  current 
of  the  blood  and  driven  into  remote  vessels.  The  whole  of  the 
process  of  the  formation  of  the  clots  is  included  under  the  term 
"  thrombosis,"  while  the  projection  onward  of  a  thrombus,  or  of 
the  fragments  detached  from  it,  and  the  phenomena  thus  occa- 
sioned, are  designated  by  the  great  pathologist  to  whom  our 
knowledge  of  the  subject  is  chiefly  due — Virchow — as  "embolia." 

The  subject  of  embolia,  or  embolism,  is  that  which  more  par- 
ticularly concerns  the  physician  in  its  immediate  practical  bearing; 
but  though  thrombi  do  not  as  often  produce  symptoms  which  the 
medical  practitioner  is  called  upon  to  be  acquainted  with  from  a 
bedside  point  of  view,  he  must  have  closely  studied  their  cause 
and  meaning  to  appreciate  those  of  many  morbid  states. 

The  embolus  may  produce  manifestations  in  the  venous  system, 
either  in  the  peripheral  veins,  or  in  the  venous  trunks  of  the 
great  internal  cavities  of  the  body ;  or  a  portion  of  the  clot  may 
have  been  washed  into  the  pulmonary  artery  from  the  right  side 
of  the  heart ;  or  it  may  have  become  impacted  in  the  arteries  of 
the  general  circulation,  in  the  larger  arteries,  or  in  those  of  fine 
calibre;  or  it  may  have  been  propelled  into  the  very  structure  of 
organs  through  these  arteries,  as  into  the  liver-structure  through 
the  hepatic  artery,  into  the  splenic  parenchyma  through  the  splenic 
artery.     Let  us  examine  a  little  more  closely  some  of  the  symp- 

*  See  the  valuable  report  of  the  Committee  of  the  Pathological  Society  of 
London,  Transactions,  1879. 


DISEASES   OF   THE   BLOOD.  743 

torns  thus  occasioned,  premising  that  arterial  embolism  is  of  much 
more  frequent  occurrence  than  the  other  forms. 

In  the  veins  thrombi  may  form,  which,  so  long  as  they  do  not 
produce  obstruction  of  the  canal,  give  rise  to  no  marked  signs.  A 
slight  hardening  and  pain  on  pressure  if  the  coagulum  be  in  one 
of  the  more  superficial  veins,  their  enlargement  if  the  clot  be  in 
a  deeper  vein,  are  apt  to  be  the  only  evidences  of  the  disordered 
condition.  But  when  the  occlusion  is  considerable,  and  especially 
when  the  collateral  circulation  is  insufficient,  cedema  is  developed, 
which  may  be  attended  with  very  great  tenderness  of  the  swollen 
part,  and,  if  the  impediment  be  of  long  duration,  with  changes 
in  the  nutrition  of  the  structures  sufficient  to  produce  phlegmo- 
nous inflammation.  These  phenomena  are  all  encountered  to 
a  greater  or  less  degree  in  milk-leg,  or  phlegmasia  alba  dolens, 
which  in  all  likelihood  depends  upon  an  obstruction  by  a  coagu- 
lum of  the  venous  circulation  in  the  affected  limb.  In  some  eases 
profuse  hemorrhages  occur  as  a  consequence  of  the  stoppage  in  the 
vein, — as  cerebral  hemorrhages  produced  by  thrombosis  of  the 
sinus,  or,  as  in  a  case  referred  to  by  Virchow,*  enormous  hemor- 
rhagic infiltration  of  the  subperitoneal  and  subcutaneous  tissues, 
as  well  as  of  portions  of  the  muscles  of  the  abdominal  walls,  as 
the  result  of  a  coagulum  in  the  external  iliac  vein,  the  epigastric, 
and  the  crural  vein. 

In  exhausting  and  wasting  diseases  blood  may  clot  in  the  veins, 
or  even  in  the  heart,  without  any  clearly-marked  cause.  Gout 
may  cause  phlebitis  and  clotting  in  the  veins  of  the  body,  as  Sir 
James  Paget  has  pointed  out.  Again,  we  may  have  chlorosis, 
giving  rise  to  thrombosis  in  the  cavities  of  the  heart  and  the 
larger  veins,  such  as  the  femorals,  without  phlebitis  preceding 
the  morbid  condition,  f 

Xow,  portions  of  the  clot,  situated  in  any  part  of  the  venous 
system,  whether  peripheral  or  not,  and  however  remote  from  the 
heart,  may  become,  by  being  broken  off  and  driven  onward  with 
the  circulation,  sources  of  great  danger.  Thus,  in  cases  of  milk- 
leg  they  may  be  propelled  from  the  veins  of  the  extremity  to  the 
heart ;  or  the  same  may  happen  when  a  clot  has  formed  in  the 

*  Pathologic  und  Therapie.  p.  172. 

j  Tuck-well,  St.  Bartholomew's  Hospital  Beports,  vol.  x.,  187-1. 


744  MEDICAL    DIAGNOSIS. 

pelvic  veins,  subsequent  to  the  ligation  of  internal  piles.  Again, 
when  the  blood  clots  in  veins  connected  with  the  portal  system, 
the  detached  fragments  may  be  washed  into  the  liver,  and  there 
lead  to  secondary  abscesses.  This,  for  instance,  is  the  most  likely 
causation  of  the  so-called  metastatic  abscesses  of  the  liver  in  dys- 
entery. But  when  coagula  occur  in  the  venous  system  and  are 
wholly  or  in  part  carried  away  with  the  circulating  blood  (if  we 
exclude  those  which,  from  their  situation,  could  only  reach  the 
liver),  we  generally  find  the  manifestations  of  disturbance  arising 
in  the  heart  or  the  lungs.  Arriving  at  the  rigid  side  of  the  heart, 
the  concretion,  if  at  all  large,  or  if  it  become  so  by  serving  as 
a  nucleus  for  a  larger  clot,  occasions  symptoms  of  exhaustion  and 
collapse  ;  an  intermitting,  feeble  pulse  ;  irregular  and  confused 
beating  of  the  heart,  and  cardiac  sounds  enfeebled  or  lost  over  the 
right  .<ide  of  the  organ  ;  rapidly  developed  distress  in  breathing, 
referred,  by  the  sufferer,  to  the  heart,*  and  signs  of  asphyxia, 
though  all  the  time  the  patient  is  taking  deep  inspirations;  great 
agitation ;  and  a  swollen  state  of  the  veins  of  the  body.  Death 
may  then  take  place  suddenly  if  a  portion  of  the  clot  separate 
and  obstruct  the  pulmonary  artery. f 

But  the  mode  of  death,  and  the  symptoms  preceding  it,  in 
embolism  of  the  pulmonary  artery,  are  not  always  the  same, 
and  depend  much  upon  the  size  of  the  embolus  and  where  it  is 
arrested.  A  large-sized  clot,  whether  it  be  merely  part  of  one 
occupying  the  right  heart,  or  be  washed  at  once  into  the  pulmo- 
nary artery,  will  occasion  the  same  signs  as  those  alluded  to  as  in- 
dicative of  a  large  clot  in  the  right  side  of  the  heart;  the  craving 
for  air  is  particularly  intense,  and  this  craving  is  increased  by 
every  movement  of  the  body ;  the  muscular  debility,  the  lowered 
temperature,  the  cyanosed  look,  the  turgid  veins  of  the  neck  and 
their  undulations,  the  increased,  irregular  cardiac  impulse,  though 
the  heart's  action  is  not  sufficiently  deranged  to  account  for  the 
disturbed  respiration  and  disordered  general  circulation,  are  also 
noticed ;  and  in  some  cases  a  systolic  blowing  sound,  and,  where 
the  case  is  at  all  protracted,  vertigo,  albuminuria,  and  cedema  of 
the  limbs,  may  be  observable.      The  intellect  is  always  apt  to 

*  B.  W.  Richardson,  Medical  Times  and  Gazette,  JSTov.  1868. 

j  As  in  a  case  recorded  by  Druitt,  Med.  Times  and  Gaz.,  July,  1862. 


DISEASES   OF   THE  BLOOD.  745 

remain  clear.  As  regards  the  pulmonary  phenomena  proper, 
collapse  of  the  lung,  hemorrhagic  effusions,  oedema,  or  capillary 
bronchitis  are  likely  to  happen,  except  in  those  instances  in 
which  the  principal  trunks  of  the  pulmonary  artery  are  blocked 
up,  and  almost  instantaneously  asphyxia  ensues.  If  the  fragments 
be  very  small,  the  amount  of  dyspnoea  is  not  of  necessity  great, 
nor  are  the  symptoms  of  asphyxia  marked ;  and  inflammations 
of  the  parenchyma  of  the  lungs  may  take  place,  occasioning 
often  secondary  obstructions  and  metastatic  abscesses  in  the  lungs. 
These  forms  of  metastatic  abscesses  are  observed  in  pyaemia,  and 
are  not  unusual  in  puerperal  fever. 

Blood  coagulates  in  the  arteries  as  a  consequence  chiefly  of  gan- 
grene and  of  ulceration.  The  vessels  for  instance  passing  from  a 
gangrenous  part  contain  coagula  forming  in  a  direction  from  the 
periphery  to  the  centre.  We  may  find  the  clots  in  gangrene  of 
internal  organs,  as  of  the  pulmonary  tissue.  Again,  inflamma- 
tion or  atheromatous  disease  of  the  coats  of  the  arteries  may  lead 
to  the  development  of  thrombi ;  so  may  feeble  action  of  the  heart 
and  increased  coagulability  of  the  blood.* 

Still,  the  most  important  phenomena  connected  with  obstruc- 
tion of  arteries  are  those  not  of  coagula  forming  in  them,  but  of 
coagula  being  washed  into  them ;  the  phenomena  of  embolism, 
therefore,  rather  than  those  of  thrombosis.  Now,  the  phenomena 
of  embolism  are  distinguished  from  those  of  the  mere  formation 
of  clots  by  what  is  always  the  most  significant  sign  of  either  ar- 
terial or  venous  embolism, — the  suddenness  of  the  manifestation 
of  the  abnormal  state.  And  in  point  of  fact  the  symptoms  arise 
not  so  much  as  the  result  of  any  of  the  conditions  alluded  to  that 
occasion  coagulation,  but  much  more  often  as  the  consequence  of 
deposits,  fibrinous  concretions,  and  excrescences  which  are  seated 
on  the  valves  of  the  left  side  of  the  heart,  portions  of  which  de- 
posits are  carried  away  by  the  circulating  blood  into  remote  parts. 
When  these  bodies  become  impacted  in  a  vessel  the  calibre  of 
which  is  such  that  it  does  not  permit  them  to  pass  on,  we  find 
rapid  changes  taking  place  in  the  portions  of  the  body  supplied 
by  the  obstructed  artery, — coldness,  pallor  of  the  parts,  a  dimin- 
ished functional  activity,  a  shrinking  ;  and  if,  as  often  does  hap- 

*  Liddell,  Araer.  Journ.  of  Med.  Sci.,  July,  1873. 


746  MEDICAL    DIAGNOSIS. 

pen,  the  first  obstruction  be  followed  by  others,  and  the  collateral 
circulation  cannot  be  established,  local  death  and  gangrene  ensue. 

All  these  changes  are,  of  course,  discernible  only  in  external 
parts,  especially  in  the  extremities ;  the  disturbances  of  function  are 
the  most  obvious  signs  where  the  internal  organs  are  the  sufferers. 
If  the  emboli  be  driven  to  the  brain,  we  have,  as  has  been  already 
alluded  to,  softening  as  the  result,  and  this  may  be  preceded  by 
disorder  of  intellect,  without  motor  disturbances,  and  by  severe 
attacks  of  vertigo,  in  cases  in  which  merely  the  smaller  arteries 
supplying  the  surface  of  the  cerebral  hemispheres  are  obstructed. 
But  where,'  as  is  indeed  the  most  common  seat  of  emboli,  the  arte- 
ries of  the  fissure  of  Sylvius  are  clogged,  the  phenomena  are  those 
of  apoplectic  hemiplegia ;  and  the  palsy  affects  the  whole  of  one 
side  of  the  body,  even  the  face,  and,  though  ushered  in  by  only 
passing  or  imperfect  unconsciousness,  is  apt  to  be  permanent. 
The  brain  may  also  suffer  from  the  seat  of  the  obstruction  being 
in  the  carotids;  indeed,  of  all  organs  the  effects  of  embolism  are 
most  plainly  perceptible  in  the  brain.  The  presence  of  emboli  in 
the  splenic,  renal,  and  mesenteric  arteries  is  generally  rather  to  be 
inferred  from  the  history  of  the  case,  and  does  not  occasion  any 
clearly  discernible  signs.  But  tenderness,  enlargement  of  the 
spleen,  and  pain  in  the  splenic  region  in  splenic  embolism,  or 
disordered  secretion  of  urine  and  pain  in  the  loins  in  embolism 
of  the  renal  artery,  may  be  very  marked. 

The  occurrence  of  pain  in  these  cases  of  internal  embolism 
must  not  be  overlooked ;  and  in  embolism  of  the  arteries  of  the 
extremities  pain  is  a  symptom  of  still  greater  prominence.  It  may 
be  like  a  violent  neuralgia,  or  so  constant  that  it  is  mistaken  for 
rheumatism ;  and,  as  happened  in  a  case  of  embolism  of  the  right 
iliac  artery,  under  the  charge  of  Dr.  James  H.  Hutchinson,* 
which  I  saw,  it  may  recur  in  paroxysms  of  intense  severity,  and 
be  referred  to  the  foot,  though  this  be  already  in  a  condition  of 
sphacelus.  Besides  the  pain,  we  are  apt  to  find  extreme  hyperes- 
thesia in  some  parts  of  the  affected  limb ;  and  pricking  sensations, 
formication,  and  loss  of  tactile  sense,  followed  by  complete  anaes- 
thesia, in  others.  Then  painful  spasms  of  the  muscles,  and  a  more 
or  less  perfect  paralysis  of  motion,  may  occur.     If  we  join  to  these 

*  Amer.  Journ.  of  Med.  Sci.,  Oct.  1863. 


DISEASES   OF   THE   BLOOD.  747 

symptoms  an  absence  of  pulsation  in  the  arteries  below  the  se- 
clusion until  the  collateral  circulation  is  decidedly  established,  a 
strong  beat  of  the  vessel  on  the  cardiac  side  of  the  obstruction,  the 
coldness  of  the  limb  below  this  obstruction,  and  the  signs  of  de- 
fective supply  of  blood,  we  have  a  group  of  phenomena  which, 
taken  in  connection  with  the  history  of  the  case,  render  the  diag- 
nosis a  positive  one.  And  in  reviewing  the  history  of  the  case 
the  state  of  the  heart  and  the  cardiac  symptoms  must  always  be 
carefully  examined  into.  It  is  there,  in  truth,  that  the  mischief 
generally  begins  ;  and  a  close  inquiry  may  show  that  the  sudden 
manifestations  of  arterial  obstruction  were  preceded  by  an  attack 
of  palpitation  and  of  irregular  action  of  the  heart. 

A  change  in  the  physical  signs  of  the  diseased  organ,  as  of  its 
murmurs,  may  not  be  evident ;  but,  should  it  be  evident,  it  is  a  sign 
of  utmost  moment.  Indeed,  any  change  in  what  may  be  viewed 
as  the  centre  from  which  the  embolus  may  be  detached  is  of  great 
significance.  And  this  holds  good  quite  as  much  for  venous  as  for 
arterial  emboli.  Thus,  in  a  case  of  coagulum  in  a  vein,  a  sudden 
disappearing  of  swelling  and  oedema  of  the  affected  limb,  with  the 
supervention  of  signs  of  embarrassed  circulation  and  respiration, 
would  at  once  tell  what  had  taken  place. 

In  regard  also  to  the  diagnosis  of  "embolism  we  must  always 
bear  in  mind  the  causes  which  are  likely  to  give  rise  to  it.  Several 
of  the  causes  of  arterial  embolism  have  already  been  mentioned  ; 
those  of  venous  embolism  are  the  same  as  of  venous  thrombosis, 
or,  to  speak  more  explicitly,  the  breaking  up  of  the  clots  and 
their  transportation  may  occur  in  any  of  the  conditions  which 
have  occasioned  them.  Now,  these  conditions,  too,  will  produce 
arterial  clots,  and  indeed  some  are  more  apt  to  lead  to  coagulation 
in  the  arteries  than  in  the  veins.  Prominent  among;  them  are  a 
narrowing  of  the  calibre  of  the  vessel,  as  by  pressure ;  dilatation 
of  the  vessels  and  of  the  heart ;  failure  or  great  diminution  of  car- 
diac power,  with  consequent  retardation  of  the  blood-stream, — a 
state  which  is  more  likely  to  occasion  venous  than  arterial  throm- 
bosis ;  a  breakage  in  the  continuity  of  the  vessel,  as  when  it  is  torn 
or  cut ;  changes  which  take  place  in  the  coats  of  the  vessels,  espe- 
cially inflammatory  changes;  and  contact  of  the  blood  within  the 
vessels  with  foreign  bodies.  Then  it  is  very  likely  that  special 
states  of  the  blood,  by  altering  the  cohesion  of  the  globules,  pre- 


748  MEDICAL    DIAGNOSIS. 

dispose  to,  if  they  do  not  absolutely  cause,  the  clotting,  which,  if 
one  of  the  other  elements  alluded  to  then  favor,  is  readily  accom- 
plished. 

Another  cause  of  embolism  is  that  due  to  accumulations  of  pig- 
ment in  the  blood,  the  result  of  malarial  fever.  The  pigment  may 
obstruct  the  capillaries  in  the  brain  and  thus  occasion  capillary 
apoplexies;  or  be  driven  to  the  liver  and  there  produce  signs  of 
disturbance  of  its  circulation,  and  abscesses.  As  in  all  forms  of 
capillary  embolism,  the  symptoms  are  obscure:  the  suddenness  of 
their  development,  generally  so  characteristic  of  the  other  forms 
of  embolism,  is  wanting;  and  the  diagnosis,  as  throughout  in 
capillary  embolia,  is  always  nothing  more  than  a  matter  of  con- 
jecture, based  on  a  close  study  of  the  general  phenomena  and  the 
history  of  the  case. 

Acute  endarteritis  may  be  the  cause  of  embolism  as  well  as  of 
pyaemia.  The  coagula  that  are  formed  break  away,  and  occasion 
embolism,  generally  in  the  smaller  peripheral  vessels ;  though 
thrombi  may  also  develop  in  the  larger  vessels,  and  pyamiic  fever 
result.  It  is  generally  impossible  to  recognize  the  malady  until 
after  the  coag-ula  are  formed,  and  then  signs  of  narrowing;  of  the 
calibre  of  a  vessel,  with  a  localized  murmur,  may  give  us  the  clue 
to  the  cause  of  the  symptoms. 

In  conclusion,  the  subsequent  changes  of  the  thrombus  must  be 
alluded  to.  It  may  organize  and  be  converted  into  connective 
tissue  and  yield  an  impaired  passage  to  the  blood;  and  perhaps 
the  collateral  circulation  may  be  freely  established ;  or,  what  is  not 
so  favorable  a  result,  it  may  soften  and  undergo  fatty  metamor- 
phosis. But  even  when  larger  portions  are  not  detached  and 
occasion  the  marked  symptoms  of  embolism,  small  ones  may  be 
wafted  into  capillaries  and  there  lay  the  foundation  of  abscesses. 
It  is  thus  that  in  a  case  of  thrombus  or  embolus  we  may  have  the 
secondary  results  of  pyaemia  to  deal  with, — metastatic  abscesses 
caused  in  the  manner  described,  and  attended  with  a  blood  pro- 
foundly altered  and  vitiated  by  the  decomposing  products  circu- 
lating in  it. 

Scurvy. — This  disease  is  not  often  met  with  in  civil  practice ; 
but  it  is  one  familiar  to  the  military  and  the  naval  surgeon.  It 
consists  in  a  deterioration  of  the  blood,  produced  by  living  for  a 
long  period  upon  the  same  kind  of  food,  and  especially  upon  salted 


DISEASES   OF   THE   BLOOD.  749 

meats,  without  the  requisite  supply  of  fresh  vegetables  being  taken. 
Indeed,  the  privation  of  the  latter  for  a  length  of  time  is  by  far 
the  most  constant  and  most  potent  cause  of  scurvy ;  so  constant 
and  potent,  in  fact,  that  it  is  by  many  regarded  as  the  sole  deter- 
mining source  of  the  disease.  Now,  this  influence  of  vegetables  is 
attributed  to  the  large  quantity  of  potassium  they  contain  ;  and,  as 
it  has  been  found  that  there,  is  a  deficiency  of  the  salts  of  potas- 
sium in  scorbutic  blood,  it  was  concluded  that  this  deficiency  is 
the  real  cause  of  scurvy.  But  this  theory  has  not  been  positively 
proved.  Another  cause  of  scurvy  is  the  want  of  proper  assimila- 
tion of  food,  as  in  prison  scurvy.* 

Scurvy  is  usually  slow  in  its  development.  The  patient  be- 
comes low-spirited,  easily  fatigued,  and  is  loath  to  exert  himself. 
The  appetite  is  impaired ;  there  is  a  craving  for  acids  and  for 
vegetable  food ;  the  tongue  is  flabby ;  the  breath  fetid ;  the  pulse 
feeble;  the  skin  dry.  The  bowels  are  usually  constipated;  but  a 
tendency  to  diarrhoea  may  exist,  and  indeed  is  apt  to  occur  as  the 
disease  advances.  Neuralgic  pains,  referred  chiefly  to  the  lower 
extremities,  to  the  bones,  and  to  the  back  or  thorax,  are  common. 
The  face  is  pale,  or  has  a  yellowish  tinge ;  the  eyes  are  surrounded 
by  a  dark  ring.  During  the  progress  of  the  ailment,  or  in  severe 
cases  almost  from  the  onset,  we  find  swollen,  spongy  gums,  which 
bleed  on  the  slightest  touch ;  hurried  breathing ;  a  rapid  pulse ; 
weakened  eyesight,  sometimes  night-blindness ;  epistaxis ;  painful 
swelling  and  hardness  about  the  joints  of  the  extremities  and  in 
the  calves  of  the  legs ;  and  purple  spots  and  bruise-like  stains  on 
the  skin.  Should  the  malady  remain  unchecked,  the  symptoms 
described  heighten  in  severity,  ulcers  form  which  have  a  fungoid 
look  and  a  great  tendency  to  bleed,  hemorrhages  take  place  from 
internal  organs,  old  sores  and  wounds  reopen,  well-knit  fractures 
become  disunited,  there  is  a  constant  tendency  to  swoon,  and  the 
patient  perishes  miserably  exhausted,  and  with  his  blood  in  a  state 
of  complete  dissolution.  It  may  be  the  cause  of  epidemics  of 
pericarditis.f  In  some  cases  death  takes  place  from  diarrhoea  or 
dropsy,  which  may  be  suddenly  developed.  Recovery  from  scurvy 
is  slow. 


*  See  Medical  Memoirs  of  the  IT.  S.  Sanitary  Commission,  p.  278. 
f  Von  Dusch,  Herzkrankheiten. 


750  MEDICAL    DIAGNOSIS. 

Purpura. — Scurvy  is  not  a  disease  difficult  to  recognize;  only 
one  affection  resembles  it  at  all  closely, — purpura.  In  this  dis- 
order also  red  or  purple  spots  or  livid  blotches,  uninfluenced  by 
pressure,  and  passive  hemorrhages  from  the  mucous  membranes, 
happen.  But  there  is  this  difference  between  the  two  complaints: 
purpura  is  common  in  fruit  seasons,  and  often  attacks  persons  who 
have  not  been  in  any  way  deprived  of  vegetable  food.  The  gums 
are  not  soft  and  spongy,  as  in  scurvy,  nor  do  we  find  the  same  weak- 
ness of  mind  and  body.  Then,  the  stain  of  the  skin  in  purpura 
is  apt  to  be  more  generally  diffused,  and  the  purple  blotches  are 
smaller,  or,  at  all  events,  the  large  patches  of  discoloration  consist 
clearly  of  an  aggregation  of  very  many  small  spots.  Moreover, 
the  disorder  is  not  controlled,  like  scurvy,  by  fresh  vegetables, 
and  by  lemon-juice, — in  fact,  by  agents  which  are  most  decided 
antiscorbutics. 

From  a  clinical  point  of  view  we  find  several  forms  of  purpura. 
In  the  mildest,  the  purpurous  spots  are  apt  to  appear  only  on  the 
legs.  They  come  in  crops,  which  fade,  and  there  are  no  constitu- 
tional symptoms,  except  a  little  lassitude,  and  perhaps  aching  of 
the  limbs  and  pain  in  the  back.  In  the  graver  cases,  "purpura 
hemorrhagica,"  we  find,  in  addition  to  the  cutaneous  hemorrhage, 
epistaxis,  hsematemesis,  hematuria,  or  other  internal  hemorrhages, 
and  extravasations  of  blood  may  happen  into  the  substance  of  the 
muscles.  The  amount  of  pain  attending  the  malady  is  very  dif- 
ferent. There  may  be  none,  or  it  may  be  trifling ;  or  deep-seated 
pains  in  the  cavities  of  the  body,  or  extended  neuralgic  pains,  may 
accompany  the  purpurous  complaint.  In  some  instances  the  pains 
are  chiefly  felt  in  and  around  the  joints,  and  the  apparently  rheu- 
matic aches  subside  in  a  few  days,  and  spots  of  extravasated  blood 
become  visible.  This  "  purpura  rheumatica,"  a  variety  particu- 
larly described  by  Schonlein,  is  usually  met  with  in  the  strong 
and  healthy.  It  is,  indeed,  one  of  the  peculiarities  of  any  kind  of 
purpura,  that  it  may  come  on  in  the  midst  of  seemingly  excellent 
health ;  for  while  it  is  true  that  the  disorder  may  be  preceded  for 
some  time  by  signs  of  general  debility,  or  occur  in  the  course  of 
disease  of  the  liver,  of  Bright's  disease,  or  as  a  sequel  to  the  exan- 
themata and  rheumatic  fever,  it  most  often  happens  where,  from 
previous  looks,  we  should  least  expect  it.  Its  production  as  the 
result  of  a  sudden  shock  to  the  nervous  system,  such  cs  fright,  and 


DISEASES   OF   THE  BLOOD.  751 

its  occasional  intermittent  character,  have  been  noticed  by  various 
observers. 

The  duration  of  the  malady  is  very  variable :  only  a  week  may 
elapse,  or  several  months  may  pass,  before  the  spots  disappear. 
Its  pathology  is  unknown.  It  is  clearly,  however,  not  merely  a 
disease  of  the  blood ;  the  capillaries  lose  their  retentiveness,  either, 
as  has  been  actually  demonstrated,  in  consequence  of  degenerative 
change,  or  as  the  result  of  impaired  power,  from  the  morbid  action 
affecting  directly  or  indirectly  the  part  of  the  nervous  system  that 
controls  them, — the  vaso-motor  system. 

In  some  cases  purpura  presents  an  acute  form.  It  is  ushered 
in  by  a  chill,  and  by  intense  pain  in  the  back  and  limbs,  but  is 
generally  unattended  with  fever  or  severe  constitutional  disturb- 
ance. The  purple  spots  usually  first  appear  on  the  legs,  and  are 
wholly  uninfluenced  by  pressure.  They  last  five  or  six  days,  or 
somewhat  longer,  then  gradually  change  their  color  and  fade. 
The  patient  feels  languid,  but,  unless  from  loss  of  blood,  his 
strength  is  not  materially  impaired.  The  effusion  of  blood  hap- 
pens in  some  cases  into  the  loose  connective  tissues  of  the  body,  or 
blood  is  lost  from  the  lungs,  and  still  more  frequently  from  the 
bowels  or  urinary  organs.  Under  these  circumstances  the  pulse, 
which  otherwise  is  apt  to  preserve  its  normal  frequency,  becomes 
very  rapid ;  but  until  exhaustion  begins  to  tell  on  the  nervous 
system — not,  as  a  rule,  long  before  dissolution — the  mind  remains 
clear,  and  cerebral  or  spinal  symptoms  are  absent.  It  is  thus  that 
we  are  able  to  distinguish  severe  cases  of  acute  purpura,  which 
may  indeed  prove  fatal  in  forty-eight  hours,*  from  spotted  fever. 

A  few  words  may  be  added  as  to  the  distinction  between  hmno- 
philia  and  purpura.  The  diagnosis  is  generally  a  simple  one.  It 
is  true  that  the  bleeding  in  a  member  of  a  bleeder's  family  may 
happen  into  the  skin  or  from  any  of  the  parts  from  which  it 
may  take  place  in  purpura;  but  the  family  history,  the  congenital 
proneness  to  frequent  hemorrhages  from  the  slightest  cause,  their 
danger  and  protraction,  the  functional  excitement  of  the  heart, 
followed  perhaps  even  by  cardiac  hypertrophy,  the  close  rela- 
tionship to  rheumatic  affections,  and  the  hemorrhagic  diathesis 
exhibited  in  heeinophilia,  stamp  this  with  very  distinctive  features. 

*  Harrison  Allen,  Ainer.  Journ.  of  Med.  ScL,  Jan.  1865. 


CHAPTER  X. 

RHEUMATISM   AND   GOUT. 

Rheumatism  and  Gout  are  affections  having  a  strong  tend- 
ency to  change  their  seat,  and  are  dependent  upon  the  presence  in 
the  blood  of  some  poisonous  material  which  probably  accumulates 
there  in  consequence  of  mal-assimilation.  The  poison  supposed  to 
occasion  the  most  frequent  of  these  disorders — rheumatism — is 
lactic  acid  ;  and  it  is  during  an  effort  at  its  elimination  that  the 
phenomena  of  rheumatism,  or  at  least  the  phenomena  of  acute 
rheumatism,  are  best  studied. 

The  rheumatic  poison  has  a  singular  predilection  for  the  fibrous, 
serous,  and  muscular  textures.  Hence  we  find  it  attacking  princi- 
pally the  joints,  the  fasciae,  the  endocardium  and  pericardium,  and 
the  muscles  in  various  parts  of  the  body.  According  to  its  main 
forms,  it  is  sometimes  divided  into  articular  and  muscular ;  but 
the  more  usual  division  into  acute  and  chronic  is  simpler,  and  will 
answer  our  purpose  best. 

Acute  Rheumatism. — Here  the  poison  gives  rise  to  the 
symptoms  of  an  acute,  active  disease,  and  attacks  especially  the 
larger  joints.  These  swell,  become  hot,  red,  tense,  tender,  and  the 
seat  of  pain  aggravated  by  the  slightest  movement ;  an  effusion 
also  takes  place  into  the  surrounding  structures,  or  into  them  and 
the  synovial  membranes  of  the  joint  itself.  The  rheumatic  inflam- 
mation may  either  remain  confined  to  the  joints  first  affected  until 
the  disease  is  over,  or,  what  is  more  common,  it  shifts  from  joint 
to  joint,  implicating  most  of  the  large  ones  in  succession,  yet  often 
invading  fresh  joints  before  the  swelling  has  subsided  in  the  parts 
first  attacked.  The  articular  disorder  is  ushered  in  and  accompa- 
nied by  high  fever,  soon  attended  with  a  full,  bounding  pulse,  with 
profuse,  sour  perspirations,  with  a  deeply-coated  tongue,  a  scanty, 
turbid,  highly  acid  urine,  and  a  countenance  expressive  of  suffer- 
ing.    The  fever  is  generally  in  proportion  to  the  number  of  joints 


RHEUMATISM   AND    GOUT.  753 

involved.  The  temperature  runs  up  to  about  102°  or  103°  Fahr. 
very  soon  after  the  outbreak  of  the  malady,  and  remains  steady, 
with  slight  evening  exacerbations  and  morning  remissions  when 
the  joint-affection  is  yielding,  but  with  renewed  rises  when  fresh 
joints  are  bejng  implicated.  As  the  disease  disappears,  the  fever 
temperature  gradually  subsides. 

There  is  ordinarily  little  difficulty  in  recognizing  the  complaint. 
The  pains  in  the  joints,  their  tumefaction  and  tenderness,  the  shift- 
ing character  of  the  disorder,  the  unimpaired  intelligence,  and  the 
peculiar  constitutional  symptoms,  form  a  group  of  phenomena 
eminently  characteristic.  In  truth,  excluding  acute  gout,  the  only 
affections  at  all  likely  to  be  confounded  with  acute  articular  rheu- 
matism are  pysemia  and  glanders,  acute  synovitis,  and  milk-leg. 
The  diagnosis  of  the  former  has  already  been  discussed  in  connec- 
tion with  diseases  of  the  blood  ;  it  only  remains,  therefore,  to  point 
out  the  marks  of  similitude  and  contrast  between  acute  articular 
rheumatism  and  the  other  maladies  just  mentioned. 

Acute  synovitis  resulting  from  an  injury,  or  from  cold,  occasions, 
like  articular  rheumatism,  pain  and  heat  in  the  joint,  with  disten- 
tion. But  the  disorder,  except,  perhaps,  if  it  happen  in  a  rheu- 
matic constitution,  does  not  affect  more  than  one  joint;  and,  as 
there  is  scarcely  any  or  no  effusion  into  the  surrounding  tissues, 
the  outline  of  the  joint  can  be  distinctly  discerned,  and  fluctuation 
is  readily  detected.  Often,  too,  the  accumulation  of  fluid  reaches 
an  extent  far  greater  than  in  rheumatic  inflammation ;  moreover, 
the  febrile  and  constitutional  derangement  is  not  so  severe  as  in 
acute  rheumatism,  and  the  affection  has  no  tendency  to  change 
its  seat.  Still,  we  must  not  forget  that  acute  synovitis  may  be 
rheumatic* 

Milk-leg,  or  phlegmasia  dolens,  occurs  most  usually  in  women 
after  delivery,  or  as  a  sequel  of  continued  fevers.  Generally,  only 
one  leg  swells,  and  this  becomes  throughout,  or  sometimes  only 
around  the  calf,  preternatural ly  white,  firm,  hot,  and  shining. 
The  tumefaction  is  uniform,  and  very  painful,  especially  so  when 
touched.  It  does  not  pit,  or  pits  but  slightly,  upon  pressure, 
except  at  the  lower  part.  There  is  in  some  cases  tenderness  with 
a  sense  of  hardness  in  the  course  of  the  femoral  vein,  though  this 


*  See  Adams,  Medical  Times  and  Gazette,  Feb.  1869. 

48 


754  MEDICAL   DIAGNOSIS. 

is  by  no  means  constant;  and  we  are  apt  to  find  signs  of  much 
debility  and  of  altered  blood  and  febrile  symptoms.  But  these 
are  unlike  the  peculiar  constitutional  disturbance  of  rheumatism, 
and  equally  dissimilar  are  the  history  of  the  case  and  the  local 
signs.  Among  the  latter,  two  giving  rise  to  striking  differences 
may  be  mentioned  :  the  almost  entire  loss  of  power  in  the  affected 
limb  in  phlegmasia  alba  dolens,  and  the  much  higher  temperature 
it  shows  by  the  thermometer  than  the  other  members.  And  while 
alluding  to  its  heat,  we  may  remark  that  an  increase  of  general 
temperature  corresponds  to  an  increase  of  pain  and  swelling  in  the 
limb,  and  of  constitutional  distress.* 

Rheumatism  may  be  modified  in  its  manifestations  by  happen- 
ing in  connection  with,  or  consequent  upon,  other  disorders.  For 
instance,  the  febrile  phenomena  may  be  of  an  adynamic  type 
when  the  disease  occurs  consecutively  to  typhoid  or  typhus  fever; 
or  we  may  find  the  local  signs  of  acute  rheumatism  strangely  mixed 
with  the  symptoms  of  puerperal  fever,  and  in  some  of  these  cases 
pus  may  fill  the  tumid  joints;  or  the  presence  of  the  syphilitic 
poison  or  of  gonorrhoea  may  imprint  peculiar  features  upon  the 
complaint. 

Thus,  in  gonorrhceal  rheumatism  there  is  usually  less  febrile  dis- 
tress ;  the  articular  pain  is  not  so  severe  or  acute ;  the  integument 
covering  the  affected  joint  is  apt  to  retain  its  normal  color ;  there 
may  be  but  one  joint — and  there  are  not  generally  many — im- 
plicated; the  inflammation  is  confined  to  the  synovial  membrane, 
and  a  copious  sero-fibrinous  exudation  occurs;  the  joint-affection, 
which  is  pre-eminently  an  affection  of  one  knee,  shows  a  tendency 
to  shift,  and  resembles  rather  an  acute  or  subacute  rheumatoid  ar- 
thritis than  acute  rheumatism ;  the  eye,  too,  unlike  what  happens 
in  ordinary  acute  rheumatic  fever,  is  often  attacked.  There  is 
no  copious  sweating,  and  no  disturbance  of  the  heart.  But 
the  most  significant  of  all  signs  is  finding  a  running  from  the 
urethra,  which  diminishes  when  the  gonorrhceal  rheumatism  sets 
in,  but  which  does  not  cease.  The  disorder  does  not  come  on 
early  in  a  case  of  gonorrhoea ;  and  the  joint-affection  appears  really 
to  be  of  pyoemic  origin.  It  disappears  only  very  slowly.  It  is 
by  all  these  signs  that  we  judge  of  the  malady  with  much  more 

*  Elliott  Richardson,  Pennsylvania  Hospital  Reports,  vol.  ii. 


RHEUMATISM   AND    GOUT.  755 

certainty  than  by  the  mere  presence  of  gonorrhoea  with  the  symp- 
toms of  rheumatism,  for  the  former  may  be  a  mere  coincidence. 

The  traits  of  an  attack  of  acute  rheumatism  are  frequently 
altered  by  certain  complications  in  internal  organs  Avhich  the  con- 
taminated blood  is  apt  to  occasion.  Prominent  among  them  are 
the  cardiac  disorders,  which  are  in  fact  so  common  that  they  may 
be  looked  upon  as  forming  part  of  the  rheumatic  manifestation 
rather  than  as  being  one  of  its  complications.  The  affection  of 
the  membranes  of  the  heart  disturbs  the  pulse  and  renders  it 
irregular,  hurries  the  breathing,  may  give  rise  to  gastric  disturb- 
ance, and,  unless  carefully  managed,  is  very  prone  to  leave  some 
lasting  mischief.  It  is,  as  a  rule,  not  difficult  of  diagnosis;  but 
this  is  a  matter  we  have  investigated  already,  while  examining 
the  signs  of  endocarditis  and  pericarditis.  Certain  cardiac  phe- 
nomena, such  as  extreme  pain  without  evidence  of  recent  valvular 
affection,  pain  which  may  shoot  to  the  neck  and  shoulder  and  be 
associated  with  signs  of  great  irritability  of  the  heart  or  of  heart- 
failure,  have  been  by  recent  observers,  as  by  Peter  and  Letulle,* 
attributed  either  to  rheumatic  myocarditis,  or  to  an  abnormal  ex- 
citement of  the  cardiac  plexus,  of  rheumatic  origin. 

Other  complications  are  inflammations  of  the  lung,  particu- 
larly of  the  bronchial  tubes  and  of  the  pleura ;  an  affection  of  the 
kidney  which  is  generally  regarded  as  due  to  pysemic  or  embolic 
infarction  ;f  and — though  not  often — cerebro- spinal  disturbances, 
exhibiting  themselves  by  headache,  violent  delirium,  convulsions, 
and  coma,  and  occurring  either  in  connection  with  a  thoracic  dis- 
order, or  solely  in  consequence  of  the  action  of  the  vitiated  blood 
on  the  nervous  centres,  or  in  consequence  of  Bright's  disease  or 
of  multiple  capillary  embolism,  or  of  the  sudden  exhaustion  of  the 
nervous  centres.  This  explanation^  has  been  more  particularly  ap- 
plied to  the  cases  in  which  an  excessive  temperature  attends  the 
rapidly-developed  signs  of  cerebral  disturbance,  a  temperature 
of  107°  or  more.  But,  speaking  from  a  bedside  point  of  view, 
we  must  remember  that  such  cases  are  comparatively  rare,  and 
that  rheumatic  delirium  is  far  from  always  of  the  same  nature. 

*  Archives  Generates  de  Medecine,  June,  1880. 

f  Chomel,  Becherches  sur  les  Reins  dans  le  Rhumatisme,  Paris,  1868;  also 
Schmidt's  Jahrb.,  No.  2,  1871. 

J  Weber,  Transactions  of  the  Clinical  Society  of  London,  vol.  i. 


756  MEDICAL   DIAGNOSIS. 

It  may  be  of  the  kind  just  mentioned.  It  may  develop  itself  with 
or  -without  the  signs  of  cardiac  complaint.  It  may  come  on  early 
in  the  disorder  during  the  violence  of  the  fever;  or  late,  and 
clearly  from  debility  and  impoverished  blood,  yielding  to  nourish- 
ment and  stimulants.  It  is  rarely  the  result  of  meningitis.  The 
delirium  which  attends  cerebral  rheumatism  may  be  marked  by 
great  talkativeness,  or,  on  the  other  hand,  the  patient  may  be 
extremely  taciturn.*  Insanity  may  follow  the  brain-symptoms 
of  acute  rheumatism. 

In  a  few  instances  of  rheumatism  we  find  arteritis  arising,  and 
especially  inflammation  of  the  fibrous  structures  of  the  aorta. 
This  condition  may  be  suspected  should  we  observe  intense  gen- 
eral uneasiness  and  distress,  with  pain,  increased  pulsation,  a  dis- 
tinct murmur  in  the  course  of  the  vessel,  and  tumultuous  action 
of  the  heart  without  there  being  obvious  signs  of  disease  of  that 
organ  present.     Still,  the  diagnosis  is  never  a  positive  one. 

Acute  rheumatism  is  not  a  disease  either  of  children  or  of  per- 
sons advanced  in  years.  Its  duration  is  very  variable.  By  judi- 
cious treatment  it  may  be  conquered  in  about  two  weeks;  but  often 
convalescence  does  not  set  in  for  three,  four,  or  five  weeks.  It 
rarely  ends  fatally;  its  cardiac  consequences  are  more  to  be  feared 
than  the  acute  attack. 

Cases  occur  not  unfrequently  in  which  the  inflammation  in  the 
joints  is  somewhat  lingering,  and  in  which  the  febrile  symptoms 
are  not  intense.  These  cases  form  an  intermediate  grade  between 
acute  and  chronic  rheumatism,  and  are  generally  spoken  of  as 
subacute.  The  disorder  is  more  apt  than  the  acute  variety  to 
affect  the  muscles  as  well  as  the  joints;  nay,  the  former  may 
be  alone  attacked.  It  may  be  witnessed  in  the  joints  of  one  ex- 
tremity, or  in  one  joint,  and  might  then  be  mistaken  for  synovitis. 
But  the  dissimilar  history  of  the  complaint  will  guard  against 
error:  no  accident  has  happened  to  account  for  the  swelling  of 
the  joint,  and  often  the  patient  will  tell  us  that  he  has  had  pre- 
viously an  attack  of  rheumatism.  The  subacute  form  of  rheu- 
matism is  very  apt  to  be  confounded  with  rheumatic  arthritis : 
we  shall  presently  refer  to  their  distinction. 


*  Some  of  these  points  are  more  fully  detailed  in  a  paper  on   Cerebral 
Rheumatism  published  in  the  Amer.  Journ.  of  Med.  Sci.,  Jan.  187-5. 


RHEUMATISM   AJSD   GOUT.  757 

Chronic  Rheumatism. — This  may  be  either  a  sequel  of  the 
acute  disease,  or  the  disorder  may  from  the  onset  assume  a  linger- 
ing form,  the  constitutional  symptoms  being  slight.  The  affection 
may  show  itself  in  the  joints,  giving  rise  to  stiffness,  dull  aching, 
pain  produced  by  motion,  but  without  heat  or  very  obvious  swell- 
ing, tenderness,  and  febrile  excitement,  or  marked  sweating;  or  it 
may  implicate  the  muscles  in  various  parts  of  the  body,  occasion- 
ing stiffness,  as  well  as  pain  when  they  are  moved ;  or  it  may 
attack  both  joints  and  muscles ;  or  it  may  be  seated  chiefly  in  the 
sheaths  of  nerves,  leading  to  what  is  called  neuralgic  rheumatism, 
of  which,  for  instance,  sciatica  often  affords  a  striking  example. 
In  any  case,  the  occurrence  of  the  pain  furnishes  the  starting- 
point  in  diagnosis,  and  we  must  ascertain,  by  careful  examination, 
whether  it  be  augmented  by  motion,  whether  it  be  more  or  less 
shifting,  whether  it  be  not  combined  with  stiffness  either  of  the 
muscles  or  of  the  joints,  whether  it  be  influenced  by  changes  of 
temperature,  whether  it  be  not  neuralgic,  or  associated  with  a  dis- 
turbance of  some  viscus,  such  as  of  the  liver  or  kidneys, — before 
we  conclude  that  the  complaint  is  really  rheumatic. 

This  is  especially  necessary  in  the  most  common  form  of  chronic 
rheumatism, — muscular  rheumatism.  All  kinds  of  pains  in  the 
muscles  or  their  surroundings,  the  cause  of  which  is  not  at  once 
apparent,  are  apt  to  be  pronounced  rheumatic.  And  indeed  it  is 
not  always  easy  to  say  whether  they  are  or  are  not  of  that  char- 
acter. We  may  distinguish  them  from  the  anguish  of  neuralgia 
by  the  pain  in  the  latter  complaint  being  ordinarily  confined  to 
the  distribution  of  one  nerve  and  not  being  increased  by  movement 
or  by  pressure;  nor  is  it  so  steady,  or  attended  with  soreness, 
except  over  a  few  spots  at  some  distance  from  one  another  in  the 
course  of  the  affected  nerve. 

As  regards  the  pains  caused  by  organic  structural  disease,  we 
can  generally  discriminate  them  from  those  of  rheumatism  by 
close  attention  to  the  history  of  the  case,  and  by  a  careful  explora- 
tion of  the  internal  organs.  Thus,  for  instance,  we  shall  find  pain 
radiating  from  the  right  hypochondrium  to  the  shoulder  to  be  de- 
pendent upon  hepatic  disease ;  or  pain  shooting  down  to  the  groin, 
thigh,  and  testicle,  to  be  caused  by  a  disturbance  of  the  kidney ; 
or  a  bearing  down  and  an  aching  near  the  sacrum,  to  be  probably 
due  to  uterine  disorder. 


758  MEDICAL    DIAGNOSIS. 

Muscular  rheumatism  may  affect  the  neck,  the  scalp,  the  mus- 
cles of  the  face,  and  the  parietes  of  the  chest  or  of  the  abdomen. 
It  may  be  not  only  chronic  in  any  of  these  situations,  but  also 
acute ;  or,  what  is  more  frequent,  when  it  occurs  with  fever  and 
is  transient,  it  is  a  sudden  acute  exacerbation  in  persons  who  are 
rheumatic  and  suffer  more  or  less  persistently  from  rheumatism, 
though  perhaps  in  a  different  part  of  the  body  from  the  one  in 
which  the  acute  affection  has  happened.  Muscular  rheumatism 
has  been  noticed  in  an  epidemic  form.* 

One  of  the  most  common  seats  of  muscular  rheumatism  is  in 
the  loins.  It  then  constitutes  the  disease  known  as  lumbago.  The 
patient  is  unable  to  stand  erect,  and  finds  it  nearly  impossible  to 
stoop  forward,  on  account  of  the  severe  pain  occasioned  when  the 
muscles  of  the  back  are  called  into  action.  Unless  the  attack  be 
very  severe  or  acute,  there  is  no  constitutional  disturbance ;  but 
the  disorder  is  often  obstinate.  It  is  easy  of  recognition.  We 
distinguish  it  from  pain  in  the  loins  due  to  disease  of  the  kidneys, 
chiefly  by  an  examination  of  the  urine,  and  by  the  different  way 
in  which  movement  affects  the  rheumatic  pain  ;  from  lumbo- 
abdominal  neuralgia,  by  the  two  or  three  sore  spots  in  the  course 
of  the  affected  nerve ;  from  rheumatism  of  the  vertebral  articula- 
tions, by  the  absence  of  tenderness  and  swelling  around  the  spi- 
nous processes;  from  lumbar  abscess,  by  the  want  of  local  bulging 
or  fulness,  of  fluctuation,  and  of  fever.  Then,  we  must  be  careful 
not  to  consider  as  lumbago  the  pain  in  the  back  caused  by  disease 
of  the  spine,  or  by  disorder  of  the  uterus,  or  by  the  passage  of  ab- 
normal urinary  constituents,  such  as  oxalate  of  lime,  or  consequent 
upon  strains,  or  blows,  or  scurvy,  or  malaria,  or  anaemia,  or  a  gen- 
eral or  local  muscular  debility. 

Thus  there  are  many  causes  of  pain  in  the  loins,  and  where  the 
case  is  of  any  duration  or  of  any  doubt  we  must  not  rest  satis- 
fied until  we  have  excluded  these  causes  from  consideration  before 
we  assume  the  disease  to  be  really  rheumatism  of  the  muscles 
and  fasciae  of  the  back.  This  caution  is  very  necessary  in  inves- 
tigating the  cases  of  (i  weak  back"  so  prevalent  among  soldiers, 
which,  though  commonly  spoken  of  as  rheumatic,  are  really, 
for  the  most  part,  due  to  strains  or  injuries  which  have  perhaps 

*  Schmidt's  Jahrb.,  No.  12,  1872. 


RHEUMATISM    AXD   GOUT.  759 

produced  a  weakness  of  the  muscle  and  a  persistent  cutaneous 
hyperesthesia ;  or  to  an  impoverished  blood,  to  neuralgia,  to 
scurvy;  or  to  digestive  disorders  attended  with  the  passage  from 
the  kidneys  of  large  amounts  of  urates  or  of  oxalate  of  lime. 

The  remarks  made  with  reference  to  this  form  of  muscular 
rheumatism  and  the  states  which  simulate  it  are  also  applicable  to 
pains  apparently  muscular,  affecting  other  portions  of  the  body. 
We  may  have  pain  and  soreness  of  the  muscles  developed  by  strain 
or  overwork  and  attended  both  with  muscular  and  with  cutaneous 
hyperesthesia, — a  condition  very  different  from  rheumatism,  and 
designated  by  Inman*  "  myalgia."  This  soreness  of  the  muscles 
is  thought  to  be  always  in  direct  proportion  to  the  debility  of  the 
muscular  system,  and  is  chiefly  caused  by  long-continued  exertion 
beyond  the  power  of  the  muscle,  or  by  a  very  ordinary  amount  of 
action  when  the  muscle  itself  or  the  individual  is  extremely  de- 
bilitated. The  morbid  state  is  most  marked  during  the  convales- 
cence from  scarlet  fever,  where  it  may  be  looked  upon  as  due  to 
over-exertion  of  the  weakened  muscles.  The  soreness  of  the  mus- 
cle is  almost  constantly  accompanied  by  heightened  sensibility  of 
the  skin  over  it ;  and  this  coexisting  cutaneous  tenderness  may  be 
in  any  case  regarded  as  an  important  diagnostic  sign.  Myalgia  is 
chiefly  found  in  the  muscles  of  the  trunk,  and  is  not  apt  to  be 
very  general. 

Another  form  of  muscular  rheumatism  to  which  we  may  here 
allude  is  the  wry-neck,  or  torticollis.  This  depends  chiefly  upon 
contraction  of  the  sterno-cleido-mastoid  muscle  of  one  side,  and 
occasions  the  ungainly  appearance  with  which  most  persons  are 
familiar.  But  we  must  be  careful  not  to  consider  every  case  as  of 
rheumatic  origin.  The  disorder  may  be  spastic,  or  may  depend 
upon  nervous  injury,  and  when  chronic  may  lead  to  alteration  in 
the  muscular  structure.  Injections  of  atropia,  hypodermically, 
may  generally  be  used,  not  only  for  their  good  therapeutic  effect, 
but  also  because,  even  in  chronic  cases,  they  may  show  us,  by  the 
difficulty  or  impossibility  of  relaxing  it,  how  much  of  the  muscle 
is  really  changed. 

Pain  in  the  muscles  and  stiffness  may  be  caused  by  still  other 
conditions  than  those  described,  and  be  mistaken  for  muscular 

*  Spinal  Irritation  Explained,  or  a  Treatise  on  Myalgia. 


760  MEDICAL   DIAGNOSIS. 

rheumatism, — the  muscular  pains  of  trichiniasis.  But  the  marked 
exhaustion  and  the  signs  of  gastro-intestinal  catarrh  are  of  such 
significance  that  they  save  us  from  error. 

A  form  of  chronic  rheumatism  which  also  may  be  briefly  men- 
tioned is  that  affecting  chiefly  the  fibrous  membranes,  such  as 
the  periosteum.  This  becomes  thick,  and  tender  on  pressure;  its 
thickening  may  even  be  very  perceptible  to  the  touch  as  well  as  to 
the  eye.  This  kind  of  rheumatism  happens  in  those  who  have 
syphilis;  but  it  also  occurs  where  no  such  taint  exists.  The  pains 
are  generally  much  more  severe  at  night ;  and  this  is  sometimes 
assumed  to  be  a  proof  of  the  syphilitic  character  of  the  disease. 
But  incorrectly  so;  for  many  varieties  of  chronic  rheumatism  are 
aggravated  by  the  warmth  of  the  bed.  Indeed,  the  only  really 
diagnostic  signs  of  syphilitic  rheumatism  are  the  obvious  evi- 
dences of  constitutional  syphilis,  or  the  history  of  the  infection. 
Still,  to  cases  in  which  several  nodes  exist,  and  in  which  the  pains 
more  particularly  affect  the  long  and  flat  bones,  and  in  which 
iodide  of  potassium  speedily  modifies  the  pains,  we  shall  be  rarely 
wrong  in  attributing  a  syphilitic  origin. 

Chronic  rheumatism  is  often  feigned,  especially  by  malingerers 
in  the  army  and  the  navy,  and  the  deception  may  be  difficult  of 
detection.  They  pretend  to  be  scarcely  able  to  walk,  or  hobble 
around  with  a  cane,  and  complain  much  of  the  pain  and  stiffness 
in  their  joints.  Yet  there  is  not  the  least  sign  of  deformity  or  real 
stiffness ;  the  pain  is  always  stated  to  be  the  same ;  and  their  gen- 
eral health  is  excellent.  Their  way  of  using  the  stick,  too,  is 
characteristic :  they  move  it  each  time  they  move  the  seemingly 
crippled  leg,  but,  as  a  rule,  not  immediately,  thus  not  employing 
it  as  a  support.  AnEesthetics  are  of  great  value  in  enabling  us  to 
decide  as  to  the  real  amount  of  immovability  of  the  limb. 

Gout. — This  disease,  so  closely  allied  to  rheumatism,  may  be, 
like  the  latter,  either  acute  or  chronic.  Instead  of  describing  its 
phenomena,  I  shall  at  once  point  out  the  marks  of  difference 
between  the  two  maladies.  In  gout,  the  small  joints  are  chiefly 
or  alone  affected ;  in  rheumatism,  the  large.  The  gouty  inflam- 
mation is  accompanied  by  more  local  pain  and  redness  than  the 
rheumatic,  and  by  cedema,  enlargement  of  the  veins,  and  desqua- 
mation of  the  cuticle,  and  implicates,  at  least  at  first,  only  one 
or  a  few  joints,  especially  the  joint  of  the  great  toe ;  while  rheu- 


RHEUMATISM   AND    GOUT.  761 

matism  attacks  the  joints  of  the  upper  as  well  as  of  the  lower 
extremities.  In  gout  there  is  a  tendency  to  disease  of  the  kidneys, 
with  a  moderate  febrile  disturbance,  and  no  profuse  sweats;  but 
we  meet  with  no  cardiac  complication,  at  least  no  valvular  affec- 
tion, as  so  constantly  happens  in  rheumatism.  Gout  is  more  de- 
cidedly hereditary  than  rheumatism ;  its  early  attacks  are  apt  to 
recur  with  a  certain  amount  of  periodicity,  and  last  about  a  week, 
— therefore  a  much  shorter  time  than  those  of  rheumatic  fever. 
During  the  paroxysm  of  gout  the  urine  is  scanty,  and  both  before 
the  attacks  and  during  the  first  days  the  uric  acid  is  strikingly 
diminished. 

Gout  occurs  generally  in  those  who  live  high  or  who  drink 
large  quantities  of  malt  liquor,  especially  in  men  about  middle 
age;  while  rheumatism  is  usually  seen  in  the  weak,  is  excited  by 
cold  and  damp,  is  as  common  in  females  as  in  males,  and  is  oftener 
found  in  the  young  and  before  middle  age.  Gout  is  frequently 
combined  with  a  deposition  of  chalk-stones  in  the  joints ;  rheu- 
matism never.  Then,  if  we  accept  the  observations  of  Garrod* 
as  conclusive,  we  possess  an  absolute  means  of  diagnosis  in  the 
examination  of  the  blood.  Uric  acid  is  always  present  in  large 
excess  in  gout,  and  absent  in  rheumatism.  This,  should  further 
researches  prove  it  to  be  an  invariable  rule,  will  be  a  positive  and 
invaluable  diagnostic  test,  and  will  render  easy  of  discrimination 
even  those  cases  which,  with  the  usually  employed  means  now 
at  our  command,  are  very  perplexing  to  distinguish.  Nor  is  the 
method  of  detecting  the  uric  acid  difficult,  if  we  make  use  of 
Garrod's  ingenious  plan.  It  consists  in  obtaining  the  crystals  of 
uric  acid,  crystallized  on  a  thread  placed  in  a  mixture  of  the  serum 
of  the  blood  or  of  the  fluid  from  a  blister  with  acetic  acid,  in  the 
proportion  of  six  minims  of  the  acid  to  each  fluid  drachm  of  the 
serum.  The  mixture  of  the  serum  and  acid  with  the  thread  in 
it  is  placed  in  a  shallow  watch-glass  and  allowed  to  stand  from 
twenty-four  to  forty-eight  hours,  protected  from  the  dust. 

Nearly  all  the  remarks  just  made  apply  more  especially  to 
the  distinction  between  acute  gout  and  acute  rheumatism.  The 
chronic  disorders  are  more  difficult  to  separate.  Indeed,  unless 
there  be  external    deposits  or  chalk-stones,  their  discrimination 

*  Gout  and  Bheumatic  Gout,  2d  edit.,  London,  1863. 


762  MEDICAL   DIAGNOSIS. 

may  be  impossible.  In  these  obscure  cases,  however,  the  history 
and  an  examination  of  the  blood  may  throw  considerable  light  on 
the  diagnosis.  In  many  subjects,  too,  the  exploration  of  the  ex- 
ternal ear  will  assist  us  in  arriving  at  a  correct  diagnosis:  we  find 
one  or  several  spots  of  deposit  of  urate  of  sodium  on  the  helix. 

Gouty  persons  are  subject  to  indigestion,  flatulency,  pains  and 
cramps,  or  palpitation  of  the  heart, — phenomena  which  are  due 
to  the  gouty  poison,  and  which  are  generally  ameliorated  by  a  fit 
of  gout.  Sometimes  the  gouty  inflammation  of  the  joints  retro- 
cedes  during  an  attack,  and  severe  epigastric  pain,  nausea,  vomit- 
ing, flatulence  and  acidity,  faintness  and  a  feeling  of  sinking,  and 
a  quick,  feeble  pulse  show  that  the  morbid  action  is  transferred 
to  the  stomach;  or  it  flies  to  the  head,  and  apoplexy  or  maniacal 
symptoms  occur;  or  to  the  heart,  and  there  is  violent  palpitation, 
with  difficulty  of  breathing,  and  intense  anxiety;  or  it  attacks 
the  spinal  cord,  and  a  sense  of  constriction  around  the  thorax  and 
abdomen,  and  piercing  pains  in  the  limbs,  like  those  of  locomotor 
ataxia,  are  encountered,  and  the  spinal  dura  mater  and  the  roots 
of  the  spinal  nerves  are  found  to  be  incrusted  with  uric  acid  and 
urate  of  sodium.* 

Now,  closely  connected  with  gout  is  lithozmia.  Indeed,  the 
excessive  formation  of  lithates  and  the  dyspeptic  symptoms,  with 
the  heartburn  and  eructations,  the  signs  of  functional  derange- 
ment of  the  liver,  the  vertigo,  the  mental  gloom  or. the  listlessness 
and  indisposition  to  exertion,  the  restless  nights,  the  palpitations 
of  the  heart,  and  its  irregular  beat,  are  in  many  but  the  pre- 
cursors, although  it  may  be  the  long  precursors,  of  a  regular  out- 
break of  gont;  while  in  many  more  this  half-dyspeptic,  half- 
nervous  condition,  with  the  faulty  assimilation,  the  imperfect 
oxidation,  the  excessive  discharge  of  lithates  at  times  and  their  dis- 
appearance at  others,  will  go  on  for  years  without  ever  developing 
into  an  attack  of  gout.  Still,  in  years  the  same  local  lesions  may 
follow  in  internal  organs ;  we  may  have  the  same  form  of  con- 
tracting kidney,  and  the  heart-affection  with  hypertrophy  and  the 
accentuated  second  aortic  sound  of  the  lithaemic  state. 

Rheumatic  Arthritis  or  Rheumatic  Gout. — Gout  is  com- 
paratively rare  in  this  country.     But  the  same  cannot  be  said  of 

*  Ollivier,  Archives  de  Physiologie,  1878. 


RHEUMATISM   AND    GOUT.  763 

that  distressing  disorder  known  as  rheumatic  gout.  This  is  gen- 
erally viewed  as  a  blending  of  the  two  diseases,  though  it  is  more 
likely  neither  rheumatism  nor  gout,  but  a  distinct  affection.  The 
disorder  may  be  acute  or  chronic.  It  is  not  often  the  former; 
many  of  the  acute  cases,  indeed,  being  rather  subacute  than  acute. 
Even  in  those  belonging  to  the  acute  form  there  is  little  febrile 
disturbance ;  and  though  we  observe  pain  and  aching  in  the  joints, 
and  some  discoloration,  we  find  less  redness  than  in  acute  rheu- 
matism, and  certainly  the  tongue  less  furred,  the  pulse  not  so 
bounding,  much  less  profuse  perspiration,  no  such  heavy  deposits 
in  the  urine,  and  an  utter  freedom  from  cardiac  complication. 
The  acute  arthritic  disease  has  rather  inflammation  of  the  pleura 
and  of  the  eye  as  its  attendants,  and  is  often  accompanied  by  a 
sallow  skin,  yellowish  conjunctiva,  and  discolored,  costive  stools. 
It  implicates  the  large  and  small  joints  equally,  thus  differing  from 
gout,  and  causes  very  great  swelling,  due  to  an  effusion,  not  around 
the  joint,  but  into  its  capsule.  It  fastens  upon  several  joints,  and, 
though  it  may  pass  from  joint  to  joint,  it  shows  but  little  migratory 
tendency ;  the  joints  first  attacked  remain  the  seat  of  disease.  Un- 
like gout,  it  is  apt  to  affect  the  smaller  joints  of  the  hands  without 
a  previous  affection  of  the  toes,  and  exhibits  no  periodic  paroxysms 
or  exacerbations.  Moreover,  an  acute  attack  is  of  very  much 
longer  duration.  Unlike  subacute  rheumatism,  it  does  not  affect 
the  muscles,  and  is,  both  in  the  suffering  at  the  time  and  in  its  ul- 
timate results,  a  much  graver  malady. 

The  great  danger  in  rheumatic  arthritis  is  from  the  effects  of 
the  inflammation  on  the  joints.  The  changes  there  produced  are 
very  obvious  in  the  chronic  form,  for  each  joint  attacked  is  apt  to 
be  permanently  damaged.  The  chronic  complaint  may  follow  the 
acute,  or  it  may  begin  without  any  febrile  symptoms,  with  pain 
and  stiffness  in  the  joints.  These  soon  become  much  distended 
with  fluid,  which  is  gradually  absorbed,  and  the  structure  of  the 
joint  alters,  the  cartilages  become,  sooner  or  later,  implicated,  and 
gradually  waste,  and  there  are  often  chronic  changes  and  perma- 
nent deformity  produced,  as  Dr.  Adams*  has  so  well  described. 
The  alterations  may  go  on  getting  worse  and  worse  in  consequence 
of  repeated  attacks,  until  complete  immobility  ensues,  and,  the 

*  Treatise  on  Kheumatic  Gout,  or  Chronic  Bheumatic  Arthritis,  etc. 


76-1  MEDICAL    DIAGNOSIS. 

joints  becoming  permanently  affected,  the  ends  of  the  bones  are 
dislocated  and  enlarged.  But,  although  there  is  much  swelling  of 
the  joints,  no  deposits  of  urate  of  sodium  are  found  in  them. 

Charcot  has  pointed  out  that  in  paralysis  ag  items,  in  addition  to 
rigidity  of  the  muscles,  deformities  of  the  fingers  result  resembling 
closely  those  of  chronic  articular  rheumatism.  But  the  likeness 
to  the  deformities  caused  by  rheumatic  arthritis  is  still  closer,  and 
to  distinguish  them  we  must  take  into  account  the  whole  history  of 
the  case,  the  tremor,  the  fixed  look,  the  peculiar  gait,  the  slow  or 
jerky  utterance,  the  sensation  of  excessive  heat.  Moreover,  the 
disfigured  joints  are  not  stiff,  and  do  not  crack. 

Rheumatic  arthritis  is  more  common  in  females  than  in  males, 
may  be,  like  rheumatism,  excited  by  cold  and  damp,  and  is  very 
apt  to  occur  in  the  weak  and  unhealthy.  It  often,  even  in  cases 
that  recover,  persists  for  months.  Xor  will  it  yield  to  the  reme- 
dies usually  administered  in  acute  rheumatism;  nor  to  colchicum 
and  the  alkalies,  so  beneficial  in  gout. 

I  shall  here  add  a  short  description  of  a  disease  of  nutrition  of 
dissimilar  character  to  those  described,  but  having  this  in  common 
clinically,  that  it  markedly  affects  the  organs  of  locomotion, — 
rickets. 

Rickets. — In  this  country  rickets  is  a  comparatively  rare  affec- 
tion, certainly  rare  as  compared  with  its  prevalence  in  England, 
in  Holland,  in  Germany,  and  in  some  other  Continental  States. 
It  is  a  constitutional  disease  of  early  childhood  connected  with  im- 
paired nutrition,  and  is  chiefly  characterized  by  increased  growth 
of  the  epiphyses  and  periosteum,  and  imperfect  ossification,  pro- 
ducing softening  of  the  bones  with  curvatures  and  distortions. 
The  changes  are  most  manifest  in  the  long  bones ;  and  the  amount 
of  organic  matter  iti  them  is  more  than  doubled,  while  the  earthy 
matter  is  scarcely  above  one-third  of  the  normal  quantity.  Be- 
sides the  osseous  changes  there  is  evident  cachexia;  and  the  liver 
and  spleen  become  enlarged  and  indurated  from  overgrowth  of 
the  glandular  elements  and  interstitial  development  of  fibroid 
tissue.  A  similar  process  may  also  happen  in  the  kidneys  and  in 
the  lymphatic  glands. 

Insufficient  and  improper  food  is  a  powerful  cause  of  rickets. 
The  malady  may  show  itself  as  late  as  the  seventh  or  eighth  year; 
but  it  most  generally  sets  in  during  the  first  or  second  year  of  life. 


RHEUMATISM   AND    GOUT.  765 

When  it  leads  to  death,  it  does  so  generally  by  gradual  exhaus- 
tion, by  impairment  of  the  digestive  functions,  by  thoracic  com- 
plications, such  as  extensive  bronchitis,  pleurisy,  collapse  of  the 
lungs  associated  with  bleeding  of  the  thoracic  walls,  by  spasm  of 
the  glottis,  by  convulsions,  or  by  chronic  hydrocephalus.  As  a 
marked  disease  it  does  not  usually  last  longer  than  a  year,  though 
the  results  of  the  osseous  changes  may  long  persist,  and,  affecting 
the  thorax  or  the  pelvis,  prove  eventually  very  injurious.  Yet  in 
time  the  bones  may  lose  their  rickety  condition  and  become  strong 
and  dense,  although  some  curvature  and  deformity  remain. 

The  beginning  of  the  disease  is  insidious.  The  child  makes  no 
attempt  at  walking,  or  ceases  to  walk  if  it  have  commenced.  It 
is  languid,  irritable,  its  face  pale,  its  tissues  flabby.  The  appetite 
fails,  there  are  thirst  and  irregularity  of  the  bowels,  or  the  marked 
signs  of  a  gastro-intestinal  catarrh.  Restlessness  at  night,  a  dis- 
position to  throw  off  the  bedclothes,  profuse  perspiration  about  the 
head,  neck,  and  chest,  while  the  rest  of  the  body  is  hot  and  dry, 
attend  an  irregular  febrile  condition  which  soon  shows  itself; 
while  fear  of  being  touched,  or  general  soreness  or  tenderness  of 
the  body  or  actual  pain,  bespeaks  the  local  process  that  is  going 
on  in  the  bones  and  their  covering.  The  changes  in  the  bones 
now  become  more  and  more  distinct.  The  joints  appear  swollen, 
especially  at  first  the  wrist  joints,  and  when  these  are  examined 
the  lower  extremities  of  the  radius  and  the  ulna  are  found  to  be 
enlarged;  similar  changes  are  perceived  in  the  tibia  and  fibula, 
and  in  the  elbow.  There  is  tenderness  along  the  ribs,  and,  should 
the  affection  continue,  nodules  are  felt  at  the  junction  of  the  ribs 
with  their  cartilages;  the  sternum  protrudes,  a  pigeon-breast  re- 
sults ;  then  the  limbs  show  contortions,  the  clavicles  are  bent,  the 
spine  may  be  curved,  the  pelvis  deformed.  The  head  is  large  and 
square,  the  forehead  high,  the  anterior  fontanel  remains  unclosed, 
the  sutures  are  open  and  thickened  on  the  sides.  A  blowing 
sound  is  frequently  to  be  perceived  over  the  cranial  sutures.  Den- 
tition is  delayed,  or  the  teeth  decay  and  fall  out.  The  urine  is 
copious  and  contains  lactic  acid  and  an  excess  of  phosphates.  In 
advanced  cases  the  symptoms  of  cachexia  are  very  marked ;  the 
flabby  muscles,  the  wan,  anseinic  aspect,  the  large  abdomen  con- 
trasting with  the  small  face,  the  enlarged  liver  and  spleen,  the 
persistent  tenderness  over  the  bones,  and  at  times  the  marked 


766  MEDICAL   DIAGNOSIS. 

fever,  give  sad  evidence  of  altered  nutrition  and  of  suffering ;  yet 
even  then  the  little  patient  may  recover,  though  most  likely  with 
part  of  the  osseous  system  irretrievably  damaged.  Of  course  we 
have  all  kinds  of  gradations  in  the  malady,  and  the  general 
symptoms  attending  the  morbid  process  may  be  slight,  just  as  the 
rickety  condition  of  the  bones  may  be  limited. 

The  diagnosis  will  have  been  made  apparent  from  the  descrip- 
tion of  the  symptoms.  In  advanced  cases  there  will  be  no  doubt. 
The  changes  in  the  bones,  the  curvature,  the  distortions,  the  ap- 
pearance of  the  patient,  the  evidences  of  cachexia,  clearly  stamp 
the  malady.  Earlier  in  the  disease  it  may  be  confounded  with 
the  manifestations  of  hereditary  syphilis.  But  this  affection  comes 
on  even  earlier  than  rickets,  almost  from  birth;  there  are  other 
signs  of  the  constitutional  taint,  including  syphilitic  coryza,  and, 
at  a  later  period,  the  notched  teeth ;  a  distinctive  history  may  per- 
haps be  obtained  ;  and  the  enlarged  bones  not  unfrequently  sup- 
purate, the  swollen  epiphyses  become  detached,  and  osteophytes 
form,  — changes  not  met  with  in  rickets. 

Mollifies  ossium  produces  deformities  which  may  be  mistaken  for 
those  of  rickets.  But  the  softening  of  the  bone  is  the  result  of  its 
disease,  and  not  of  its  want  of  proper  ossification.  There  is  consid- 
erable difficulty  in  locomotion,  and  the  bones  bend  or  break,  after 
having  been  affected  with  deep-seated  pains.  The  malady  lasts  for 
years,  and  is  not  one  of  childhood,  being  most  common  between 
the  ages  of  twenty-five  and  forty,  and  attacking  chiefly  women. 
The  pelvic  bones  are  often  implicated  ;  it  is  doubtful  if  the  phos- 
phates in  the  urine  are  increased,  but,  as  in  rickets,  the  urine  con- 
tains lactic  acid.  But  there  are  not  the  characteristic  signs  at  the 
cranial  bones,  the  open  fontanel  and  sutures,  nor  the  swelling  of 
the  epiphyses,  which  this  malady  so  strikingly  presents. 

Some  of  the  local  deformities  that  result  and  the  diseases  with 
which  they  may  be  confounded,  as  of  the  thorax  and  of  the  head, 
have  been  elsewhere  discussed.  Besides  the  alteration  of  the  skull 
in  chronic  hydrocephalus,  the  condition  described  by  Elsaesser 
and  others  as  craniotabes  may  be  mistaken  for  ordinary  rickets. 
It  consists  in  thinning  of  the  bones  of  the  cranium,  especially  of 
the  occipital  bone,  which  becomes  perforated,  allowing  the  mem- 
branes of  the  brain  to  come  in  contact  with  the  under  surface  of 
the  scalp,  and  convulsions  may  be  induced  by  undue  pressure  over 


RHEUMATISM    AND    GOUT.  767 

the  points  of  perforation  of  the  bone.  The  malady,  though  re- 
garded by  some  as  a  separate  affection,  is  by  others,  by  Virchow 
among  them,  looked  upon  as  due  to  a  rachitic  diathesis ;  we  cer- 
tainly often  find  evidences  of  this  in  conjunction  with  the  peculiar 
alteration  of  the  bones  of  the  skull. 

In  the  early  stages  of  rickets  it  may  be  mistaken  for  acute  or 
subacute  rheumatism ;  the  fever,  the  pain,  the  sweats,  and  the 
swelling  near  the  joints  mislead.  But  the  age  of  the  little  patient, 
the  swelling  of  the  epiphyses,  the  absence  of  redness  of  the  joints 
and  of  heart-lesion,  the  "  beading"  of  the  ribs,  the  signs  of  be- 
ginning cachexia,  the  faulty  dentition,  and  the  pale  urine  full  of 
phosphates,  tell  the  true  meaning  of  the  symptoms.  Moreover, 
the  apparent  joint  affection  is  apt  to  show  itself  at  the  wrist  joints, 
always  a  suspicious  circumstance  in  young,  delicate  children. 


CHAPTER    XI. 

FEVEES. 

The  lassitude,  the  heat  of  skin,  the  excited  circulation,  and 
the  altered  secretions, — in  one  word,  the  group  of  morbid  actions 
recognized  as  fever,  are  often  consequent  upon  some  strictly  local 
malady.  But  here  the  fever  is  a  symptom,  and  does  not  consti- 
tute the  only  obvious  affection  present.  It  is  only  in  the  latter 
case  that  the  disorder  merits  the  name  of  essential  fever.  The 
first  step,  therefore,  when  fever  has  been  recognized,  is  to  de- 
termine whether  it  is  symptomatic  or  idiopathic;  whether,  in 
other  words,  it  is  but  a. complement  to  a  disease,  or,  as  far  as  can 
be  ascertained,  the  disease  itself.  This  is  not  generally  a  difficult 
matter.  The  history  of  the  case,  the  absence  or  presence  of  the 
marked  peculiarities  of  serious  local  disturbances,  soon  determine 
the  scale  of  evidence  to  rise  on  the  one  side  or  sink  on  the  other. 
And  it  is  astonishing,  with  the  progress  of  medicine,  how  many 
affections  have  been  passed  over  from  the  domain  of  fevers  to  the 
narrower  circle  of  inflammation  of  individual  organs;  how  many 
a  case  of  gastric  fever,  for  instance,  turns  out  to  be  a  subacute  in- 
flammation of  the  stomach  ;  and  with  what  a  different  eye  the 
brain  and  lung  fevers  of  the  olden  times  are  regarded.  While 
thus  the  group  of  idiopathic  fevers  has  been  considerably  win- 
nowed, some  of  their  broad  traits  have  been  very  prominently 
brought  forward.  It  is  now  well  understood  that,  with  some 
exceptions,  they  are  characterized  by  the  want  of  definite  and 
invariable  anatomical  lesions.  That  in  all  constant  changes  occur 
in  parts  of  the  nervous  system,  or  in  the  blood,  is  highly  prob- 
able ;  but  these  changes  are  not  of  a  nature  to  be  recognized  by 
our  present  means  of  research.  Certainly  there  is  no  invariable 
injury  perceptible  in  the  organs  of  the  body:  sometimes  one, 
sometimes  another,  suffers;  sometimes  nearly  all;  at  times,  none. 
When  we  contrast  this  with  symptomatic  fever,  the  difference  is 
striking. 
768 


FEVERS.  769 

The  visceral  lesions,  then,  of  an  idiopathic  fever  are  not  the 
starting-point  of  the  fever ;  but  rather  secondary  and  uncertain 
complications  influenced  by  and  subordinate  to  the  profound  dis- 
turbance of  the  whole  system.  In  idiopathic  fever,  the  fever 
controls  the  lesions ;  in  symptomatic  fever,  the  lesions  control  the 
fever. 

Most  fevers  run  a  definite  course,  showing  a  strong  tendency  to 
a  spontaneous  termination  at  a  given  time.  At  their  beginning, 
too,  they  are  for  the  most  part  similar.  There  is  a  prodromic 
state,  marked  generally  by  unsound  sleep,  pain  in  the  back,  and 
lassitude.  This  is  followed  by  chills,  which  are  succeeded  by  heat 
of  skin,  arrested  secretions,  quick  pulse,  and  evident  fatigue  upon 
the  least  exertion.  The  fever  has  now  reached  its  full  develop- 
ment. Its  precise  character  becomes  evident ;  the  symptoms  caused 
by  disorders  of  individual  organs  stand  forth.  After  a  while  the 
disturbance  declines,  or  speedily  ceases  under  the  influence  of  criti- 
cal discharges.  The  functions  are  re-established,  and  a  convales- 
cence, more  or  less  rapid,  sets  in.  An  unfavorable  termination, 
on  the  other  hand,  may  take  place  at  any  period  after  the  system 
has  been  fairly  invaded. 

Such  is  a  brief  outline  of  the  general  phenomena  of  a  fever. 
But  varied  causes  and  secondary  changes  of  course  modify  these 
phenomena,  and  occasion  signs  serving  to  distinguish  one  febrile 
disorder  from  another.  In  some,  the  fever  is  continued ;  in 
others,  it  exhibits  a  distinct  periodicity.  Again,  some  fevers  are 
attended  with  symptoms  of  extremely  high  action ;  others,  with 
the  signs  of  most  profound  prostration  and  blood-poisoning. 

The  marked  features  impressed  upon  the  fever,  either  by  the 
course  it  runs  or  by  the  specific  nature  of  the  symptoms,  go  to 
form  what  is  called  its  type,  and  may  be  made  the  basis  of  the 
classification  of  all  febrile  disorders.  But  as  opinions  have  been 
and  are  still  singularly  diversified  as  to  what  really  constitute  the 
most  palpable  characteristics,  so  the  classification  of  fevers  is  as 
yet,  to  a  great  extent,  a  matter  of  speculation.  Nor  has  the  diffi- 
culty been  lessened  by  the  disposition  to  assign  a  separate  place  to 
each  fever  presenting  any,  however  minute,  points  of  dissimilarity. 
Certain  it  is  that  very  many  divisions  are  uncalled  for ;  for  Nature 
herself,  by  the  readiness  with  which  she  permits  even  essential 
traits  to  be  interchanged  or  to  become  blended  in  the  same  attack, 

49 


770 


MEDICAL    DIAGNOSIS. 


proves  that  even  groups  are  not  widely  distinct,  and  that  minor 
differences  are,  therefore,  wholly  unworthy  of  forming  the  touch- 
stone of  systematic  arrangement.  In  the  following  table  no  attempt 
is  made  at  an  exhaustive  or  strictly  scientific  classification.  Some 
disorders,  such  as  cholera,  epidemic  dysentery,  and  puerperal  fever, 
considered  by  many  eminent  pathologists  to  belong  to  idiopathic 
fevers,  have  no  place  assigned  to  them  ;  while  others,  such  as  in- 
fluenza and  yellow  fever,  the  claims  of  which  to  be  here  mentioned 
are  undoubted,  might  have  their  positions  fairly  impugned.  But 
in  a  diagnostic  point  of  view  the  arrangement  adopted  is  conve- 
nient, and  is  sufficiently  accurate  to  be  free  from  grave  objections. 


Fevers. 


Continued  Fevers. 


Periodical  Fevers. 


'  Simple  continued  fever. 

Catarrhal  fever  or  influenza. 

Typhoid  fever. 
h    Typhus  fever. 

The  Plague. 

Cerehro-spinal  fever. 

Eelapsing  fever. 

Intermittent  fever. 
Remittent  fever. 
Congestive  fever. 
Yellow  fever. 


Eruptive  Fevers. 


Scarlet  fever. 

Measles. 

Eubeola. 

Smallpox. 

Varicella. 

Miliaria. 

Dengue. 

Erysipelas. 


Continued  Fevers. 

All  continued  fevers  are  characterized  by  a  steady  progress  of 
the  febrile  movement,  without  either  decided  exacerbation  or  re- 
laxation, the  rise  and  fall  observable  being  too  slight  to  modify 
the  impression  of  a  sustained  action. 

Simple  Continued  Fever. — Simple  fever  sets  in  with  feel- 
ings of  lassitude  and  chilliness ;  to  these  succeed  hot  skin,  excited 
pulse,  thirst,  headache,  pain  in  the  limbs.     The  bowels  are  gen- 


FEVERS.  771 

erally  confined,  the  urine  high-colored.  The  fever  is  soon  at  its 
height;  it  then  either  gradually  declines,  or  is  more  suddenly 
relieved  by  copious  perspiration  or  by  a  critical  discharge  from 
the  bowels.  Generally  it  runs  through  all  these  stages  in  a  few 
days ;  but  it  may  be  protracted  for  upward  of  a  week.  On  the 
other  hand,  a  day  may  witness  both  its  beginning  and  its  termi- 
nation.   The  convalescence  is  almost  always  rapid. 

The  exciting  causes  of  this  form  of  fever  are  fatigue,  errors  in 
diet,  change  in  mode  of  life,  exposure  to  cold  and  moisture,  or  to 
the  sun.  "When  brought  on  by  mental  overwork  or  by  anxiety  or 
grief,  it  is  not  uncommonly  attended  with  increased  sensibility  of 
the  skin,  and  with  considerable  prostration,  simulating  typhoid 
fever,  but  differing  from  it  by  the  absence  of  epistaxis,  of  the  pe- 
culiar abdominal  symptoms,  and  of  the  eruption.  More  frequently 
the  fever  has  the  appearance  of  one  of  high  action.  At  times,  in- 
deed, it  is  so  intense,  and  the  vascular  system  so  wrought  up,  that 
the  distemper  assumes  what  is  called  an  inflammatory  type.  It 
now  exhibits  the  characteristics  of  the  fever  described  by  the  phy- 
sicians of  the  last  century  as  synocha.  Burning  heat  of  the  sur- 
face, throbbing  of  the  temporal  arteries,  severe  headache,  and  de- 
lirium are  among  its  symptoms.  This  variety  of  the  fever  is  not, 
however,  a  disease  at  present  encountered,  save  in  tropical  lati- 
tudes. In  point  of  diagnosis,  it  is  most  apt  to  be  confounded  with 
internal  inflammations,  especially  with  inflammation  of  the  brain. 
On  the  history  of  the  case,  and  on  the  full  consideration  of  all  the 
symptoms  before  us,  alone  can  a  trustworthy  opinion  be  based.  In 
truth,  in  all  the  grades  of  what  appears  to  be  at  first  sight  simple 
continued  fever,  we  ought,  before  assuming  the  febrile  state  to  be 
the  disease  and  sufficient  to  explain  the  abdominal  phenomena,  to 
examine  carefully  all  the  organs  and  see  whether  the  symptoms 
may  not  be  wholly  accounted  for  by  some  visceral  disturbance. 
And  often,  then,  under  what  seems  to  be  a  very  active  or  "ardent" 
fever  will,  on  closer  scrutiny,  be  found  lurking  the  traits  of  an  in- 
flammatory lesion. 

Catarrhal  Fever. — This  epidemic  malady,  which  belongs  to 
the  idiopathic  fevers,  is  often  described  as  a  mere  variety  of  bron- 
chitis, because  inflammation  of  the  bronchial  mucous  membrane 
constitutes  one  of  its  most  prominent  symptoms.  But  this  is  not 
a  just  view.     With  as  much  reason  might  typhoid  fever  be  omitted 


772  MEDICAL    DIAGNOSIS. 

from  the  list  of  febrile  maladies  and  described  as  a  variety  of 
enteritis  or  of  diarrhoea. 

Catarrhal  fever,  or  influenza,  is  essentially  an  epidemic  disease, 
and  one  which  has  visited  the  human  race  from  remote  antiquity. 
Its  history  is  thus  not  confined  to  any  particular  time,  or  to  any 
particular  nation ;  yet,  in  spite  of  its  frequency  and  wide  preva- 
lence, its  cause  is  still  unascertained.  We  know  nothing  further 
of  it  than  that  it  is  an  atmospheric  poison,  traversing  continents 
with  extreme  rapidity,  just  as  cholera  does,  affecting  animals  as 
well  as  man,  and  leaving  behind  it  an  influence  which  shows  itself 
long  after  the  epidemic  visitation.  But  what  this  state  of  the 
atmosphere  is,  which  produces  such  potent  results,  is  not  under- 
stood. It  is  certainly  neither  heat,  nor  cold,  nor  damp,  nor  any 
recognizable  physical  changes  in  the  surrounding  air;  for  the 
disease  has  occurred  at  all  times  of  the  year,  and  in  every  kind 
of  weather. 

Each  epidemic  does  not  furnish  precisely  the  same  train  of 
symptoms;  but  they  all  agree  in  this:  the  disorder  sets  in  sud- 
denly, and  attacks  pre-eminently  the  mucous  membranes.  Gen- 
erally it  is  the  mucous  membrane  of  the  nose,  eyes,  and  bronchial 
tubes  which  suffers  most,  and  we  find  the  signs  of  coryza  and  of 
bronchial  inflammation, — a  watery  eye,  sneezing,  uneasiness  about 
the  throat,  and  a  tormenting  cough.  But  associated  with  these 
are  great  depression  of  spirits  and  usually  an  extraordinary  amount 
of  lassitude  and  impairment  of  strength ;  much  more  than  the  cold 
in  the  head,  or  the  laryngitis,  or  the  bronchitis  will  account  for. 
The  skin  is  hot,  at  times  covered  with  perspiration;  the  ther- 
mometric  record  is  peculiar  only  in  its  extreme  irregularity ;  the 
pulse  is  of  moderate  volume,  or  weak,  the  tongue  white  and  coated  ; 
the  patient  complains  of  debility,  and  of  the  headache  and  of  the 
aching  pains  in  his  back  and  limbs.  Often  there  is  some  dyspnoea 
as  well  as  epistaxis,  hyperesthesia,  especially  of  the  neck  and  head, 
and  disturbance  of  the  alimentary  tract,  evinced  by  loss  of  appe- 
tite, nausea  and  vomiting,  or  by  diarrhoea.  Commonly  after  three 
or  four  days  these  symptoms  begin  to  subside,  the  cough  and  de- 
bility outlasting  the  other  morbid  signs.  With  reference  to  the 
cough  we  are  often  struck  by  the  fact  that  its  obstinacy  and  vio- 
lence are  not  associated  with  adequate  physical  signs  of  disorder. 
It  is  often  very  dry  and  harassing. 


FEVEBS.  773 

But  all  epidemics  do  not  run  precisely  this  course.  In  some, 
the  prostration  is  not  so  evident,  and  the  febrile  signs  are  more 
active  and  of  an  inflammatory  type ;  in  others,  the  pain  and  sore- 
ness in  the  limbs  and  in  the  joints  constitute  the  most  prominent 
symptoms;  or  we  may  find  hernicrania,  or  torpor  and  delirium, 
or  parotitis  with  salivation,  or  otitis,  or  epistaxis,  or  jaundice,  or 
capillary  bronchitis,  or  pneumonia,  as  complications- 
Influenza  is  not  ordinarily  in  itself  a  fatal  disease.  It  is  only 
so  in  the  very  young  or  the  very  old,  in  both  of  whom  it  is  apt 
to  become  combined  with  inflammation  of  the  smaller  bronchial 
tubes  or  of  the  lung. 

Catarrhal  fever  is  easily  discriminated  from  other  maladies. 
Its  peculiar  epidemic  character,  and  the  prostration,  prevent  us 
from  mistaking  an  ordinary  cold  or  bronchitis  for  it.  Occasion- 
ally the  attending  debility  makes  it  look  like  the  onset  of  a  low 
continued  fever.  But  brain-symptoms  are  present  only  in  rare 
instances  in  influenza ;  and,  on  the  other  hand,  decided  catarrhal 
symptoms  are  not  common  in  typhoid  or  typhus  fever.  Before 
long,  too,  the  occurrence  of  the  eruption  of  these  diseases  clears  up 
whatever  doubt  may  have  existed.  The  all  but  constant  absence 
of  an  eruption  in  influenza  comes  also  elsewhere  into  play:  it 
serves  to  distinguish  this  disorder  from  measles  or  smallpox. 

When  influenza  is  prevailing  on  a  large  scale,  it  is  often  found 
peering  out  from  under  the  garb  of  other  diseases,  and  it  may  be 
difficult  then  to  separate  its  manifestations  from  those  of  the 
malady  it  accompanies. 

Typhoid  Fever. — In  this  country  and  on  the  continent  oi 
Europe  a  form  of  continued  fever  largely  prevails,  marked  by 
great  prostration  and  disturbance  of  the  nervous  system,  and 
by  constant  anatomical  lesions.  To  this  disease  the  various  desig- 
nations of  typhoid  fever,  enteric  fever,  entero-mesenteric  fever, 
nervous  fever,  and  abdominal  typhus  have  been  applied. 

The  disorder  either  attacks  single  individuals,  or  shows  itself  as 
an  epidemic.  It  occurs  at  all  seasons  of  the  year,  but,  in  this 
country  at  least,  is  most  frequent  in  autumn.  In  some  localities 
it  is  thoroughly  at  home ;  in  others  it  is  only  occasionally  seen. 
It  avoids  both  extremes  of  age,  seizing  mainly  on  young  adults 
for  its  victims.  It  is  not  a  contagious  malady ;  its  chief  exciting 
cause  is  defective  sewerage. 


774  MEDICAL    DIAGNOSIS. 

The  distemper  may  set  in  suddenly,  but  more  generally  it  has 
an  insidious  beginning.  For  some  days  preceding  the  access  of 
the  fever  the  patient  feels  weak  and  out  of  spirits.  He  is  listless 
and  without  animation,  and  his  countenance  fully  expresses  his 
languor.  He  complains  of  soreness  and  fatigue,  of  dull  pain  in 
the  head,  of  loss  of  appetite.  His  sleep  is  unsound ;  all  exertion 
is  wearisome.  He  is  sick ;  something  is  evidently  weakening  his 
nervous  energies.  A  fever  now  appears,  preceded  mostly  by  a 
chill,  or,  at  all  events,  by  chilly  sensations,  which  alternate  with 
flushes  of  heat.  The  muscular  prostration  accompanying  the 
febrile  movement  is  so  great  that  the  patient  is  obliged  to  seek 
his  bed.  His  appetite  is  entirely  gone,  the  tongue  is  coated,  the 
bowels  are  loose,  the  abdomen  is  somewhat  swollen  and  tender  to 
the  touch.  On  close  inspection,  a  few  reddish  spots,  resembling 
flea-bites,  are  found  on  its  surface. 

The  malady  has  now  completed  its  first  week.  It  enters  the 
second  week  with  fever  unabated,  and  with  the  signs  of  disturb- 
ance of  the  alimentary  tract  and  of  the  nervous  system  more  and 
more  unmistakable.  There  is  sometimes  nausea  or  epigastric  dis- 
tress, often  pain  in  the  right  iliac  fossa,  increased  by  pressure,  and 
tympanites.  The  tongue  dries  and  becomes  reddish  or  brownish, 
it  is  often  glazed  and  covered  with  a  light  coat,  sometimes  it  has 
deep  fissures ;  very  frequently  I  have  noticed  at  the  tip  a  wedge 
of  brownish  or  reddish  surface  free  from  coat,  but  which  begins  to 
be  covered  over  as  the  disease  declines ;  the  gums  and  teeth  are 
lined  with  dark  crusts.  The  mind  is  dull  and  wandering ;  cough 
and  great  restlessness  exist;  the  debility  is  extreme. 

The  disease  now  begins  to  draw  to  its  close.  It  has  reached 
the  third  week,  and  a  change,  for  better  or  for  worse,  may  be 
looked  for.  Slowly  recovery  sets  in,  marked  by  a  brightening 
of  the  countenance  and  by  a  gradual  increase  in  consciousness 
and  strength ;  or  deepening  insensibility,  jerking  of  the  tendons, 
feeble  pulse,  and  cold,  clammy  sweats  indicate  that  dissolution  is 
fast  approaching. 

Thus,  in  one  way  or  the  other,  the  fever  itself  is  apt  to  ter- 
minate by  the  beginning  of  the  fourth  week.  Yet  such  is  not 
always  the  case.  Death  may  take  place  at  an  earlier  period  ;  or, 
on  the  other  hand,  the  malady,  by  troublesome  complications,  may 
be  lengthened  beyond  the  second  month.      Under  any  circum- 


FEVEES.  775 

stances,  convalescence  is  protracted.     The  nervous  system  rallies 
but  gradually  from  the  shock  it  has  received. 

Among  the  symptoms  enumerated,  some  are  so  striking,  and 
tend  so  clearly  to  characterize  the  disease,  that  in  examining 
them  more  closely  we  become  at'  once  familiar  with  the  fea- 
tures distinguishing  typhoid  fever  from  a  host  of  other  maladies. 
And  first,  of  the  more  purely  febrile  symptoms.  The  skin  is 
hotter  than  natural ;  this  is  especially  perceptible  in  the  evening 
exacerbations  of  the  fever.  Frequently  the  surface  is  covered 
with  an  acid  perspiration,  very  manifest  during  the  whole  course 
of  the  disorder,  and  also  encountered  long  after  convalescence 
has  set  in.  The  pulse  is  accelerated,  and  remains  so  after  the 
heat  of  skin  has  left ;  but  it  is  rarely  tense,  and  even  in  intercur- 
rent acute  inflammations  it  seldom  loses  its  compressibility.  A 
jerking,  irregular  beat,  or  very  great  rapidity,  is  an  unfavorable 
sign. 

When  we  investigate  the  febrile  symptoms  by  the  thermometer, 
we  find  them  striking  and  peculiar.  Wunderlich's  observations 
on  very  many  cases  show  that  the  temperature  on  the  first  day  of 
the  fever,  in  the  morning,  may  be  stated  at  98.5°,  in  the  evening 
at  100.5°  Fahr. ;  on  the  second  day,  in  the  morning  it  is  apt  to  be 
about  99.5°,  in  the  evening  101.5°  ;  on  the  third  day,  in  the  morn- 
ing 100.5°,  in  the  evening  102.5° ;  on  the  fourth  day,  in  the 
morning  101.5°,  in  the  evening  104°.  From  that  time  on,  the 
evening  temperature  ranges  between  103°  and  104°,  the  morning 
temperature  being  about  1  degree  lower,  until  the  middle  of  the 
second  week,  when,  certainly  in  the  milder  cases,  although  the 
evening  temperature  may  remain  quite  or  nearly  as  high,  there  is 
an  abatement  of  heat  of  1°  to  2°  in  the  morning.  These  changes 
between  morning  and  evening  become  very  evident  toward  the  end 
of  the  week,  and  are  still  more  evident  in  the  third  week,  when 
the  morning  and  evening  temperatures  may  vary  between  4° 
and  6°.  During  this  week,  too,  the  evening  temperature  gradu- 
ally decreases ;  but  in  severe  cases  it  remains  high,  and  there  are 
no  decided  remissions,  either  in  the  second  or  the  third  week.  The 
morning  temperature  is  high,  104°  or  more,  and  there  may  be 
still  greater  heat  of  skin  in  the  evening,  or  else  it  differs  but  little 
from  that  of  the  morning.  The  peripheral  temperature,  as  meas- 
ured for  instance  in  the  palm  of  the  hand,  becomes  during  the 


776  MEDICAL    DIAGNOSIS. 

fever  as  high  as  the  axillary  temperature,  but  their  equalization 
ceases  prior  to  defervescence.* 

Among  the  abdominal  symptoms,  diarrhoea  is  the  most  promi- 
nent. It  is  never  absent,  except  when  the  disease  is  unusually 
mild.  Generally,  it  is  a  very  early  symptom.  The  clue  to  its 
cause  is  found  in  the  state  of  the  abdominal  glands;  in  the  en- 
largement and  ulceration  of  the  glands  of  Peyer  and  of  the  solitary 
glands,  and  in  the  tumefaction  of  the  mesenteric  glands.  And  in 
these  morbid  alterations  we  find  an  explanation  not  only  of  the 
occurrence  of  the  diarrhoea,  but  also  of  its  frequency.  The  stools 
are  thin,  of  a  yellow  or  dark-brown  color,  and  of  offensive  Smell. 
When  the  affection  is  at  its  height,  from  three  to  four  evacuations 
occur  during  the  twenty-four  hours ;  but  the  passages  may  become 
much  more  numerous,  and  with  their  number  the  danger  rises. 
If  they  take  place  without  the  knowledge  of  the  patient,  his  situ- 
ation is  precarious.  Sometimes  the  stools  contain  blood.  Should 
this  be  present  in  considerable  quantity,  it  is  a  very  unfavorable 
circumstance.  Yet  intestinal  hemorrhage  is  by  no  means  neces- 
sarily fatal. 

Enlargement  of  the  spleen  is  a  very  constant  attendant  upon  the 
fever.  In  fact,  whenever  we  can  be  certain  that  the  evident  in- 
crease in  size  is  not  due  to  some  previous  malady  or  to  malaria, 
the  extended  percussion  dulness  in  the  splenic  region  becomes 
an  element  of  importance  in  our  diagnosis. 

Another  abdominal  symptom  of  significance  is  pain.  It  varies 
much  in  severity  and  character,  and  is,  indeed,  not  always  present. 
It  is  often  a  heavy,  aching  feeling.  In  some  patients  it  is  of  a 
griping  kind,  preceding  the  loose  discharges;  in  others,  it  seems 
to  be  called  into  existence  only  by  pressure.  Its  most  common 
seat  is  in  the  iliac  fossse ;  yet  the  testimony  of  the  sick  man  him- 
self as  to  its  exact  situation  must  be  received  cautiously.  He  is 
too  ill  to  answer  intelligently,  is  apt  to  reply  in  the  affirmative  to 
any  leading  question,  and  thus  may  be  made  to  say  that  almost 
any  part  hurts  him  which  is  touched.  Still,  the  expression  of 
suffering  on  his  face,  when  pressed  on  either  side  at  the  lower  part 
of  the  abdomen,  is  strongly  indicative  of  the  pain  corresponding, 
for  the  most  part,  to  the  seat  of  the  irritation.     In  rare  instances, 

*  Couty,  Archives  de  Physiologie,  No.  2,  1880. 


FEVEES.  777 

however,  the  pain  is  really  in  the  muscles,  which  may,  indeed, 
suppurate.*  Ofteu,  while  the  hand  is  exploring  the  abdominal 
regions,  a  movement  of  the  fluid  and  gas  in  the  distended  bowel, 
attended  with  a  gurgling  noise,  becomes  appreciable.  This  sign  is 
best  elicited  near  the  ileo-csecal  valve,  and  is  full  of  meaning. 

During  convalescence,  griping  pains  are  not  unfrequently  com- 
plained of.  They  are  colicky  pains,  produced  generally  by  errors 
in  diet,  and  may  be  followed  by  a  return  of  the  diarrhoea  or  by  a 
relapse  of  all  the  other  symptoms  of  the  malady.  Occasionally 
— fortunately  not  often — during  such  a  relapse,  or  even  during 
the  latter  period  of  the  fever,  a  sudden  pain  sets  in,  of  great  in- 
tensity, unremitting,  and  attended  by  spreading  tenderness.  Such 
a  pain  forebodes  evil.  It  shows  that  peritoneal  inflammation  has 
been  lighted  up  in  consequence  of  the  intestine  having  been  per- 
forated. 

Hardly  inferior  to  the  abdominal  symptoms  in  import — in 
many  respects  of  even  greater  significance — are  the  signs  of  dis- 
turbance of  the  nervous  system.  The  fever  is,  as  its  old  name 
implies,  pre-eminently  a  "  nervous"  fever :  the  nervous  symptoms 
are,  in  truth,  never  absent ;  but,  though  always  present,  they  are 
less  extensive  in  some  cases  than  in  others,  and  not  the  same 
throughout  all  the  stages  of  the  disease.  Thus,  early  in  the  dis- 
order, dull  headache,  mental  languor,  wakefulness,  and  a  perverted 
state  of  the  senses,  such  as  ringing  in  the  ears  and  dulness  of  hear- 
ing, are  encountered  ;  while  later,  great  restlessness,  delirium,  som- 
nolence, or  coma,  and  jerking  of  the  tendons  are  phenomena  more 
likely  to  be  met  with.  The  delirium  especially  requires  to  be 
noted.  It  sets  in  generally  during  the  second  week,  for  the  most 
part  at  night,  and  terminates  with  convalescence  or  else  ends  in 
coma.  It  is  not  a  wild  delirium,  but  a  confusion  of  mind  asso- 
ciated with  rambling  thoughts.  If  the  patient's  attention  be 
strongly  engaged,  he  may  almost  always  be  roused,  and  does  for  a 
time  as  he  is  told ;  but  after  a  short  interval  his  muttering  lips 
indicate  that  some  curious  fancy  has  again  taken  possession  of  him. 
In  some  cases,  not  in  many,  the  delirium  is  attended  with  great  rest- 
lessness and  agitation,  and  the  sick  man,  if  not  prevented,  attempts 
to  walk  about  the  room.     This  kind  of  frenzy  often  ends  in  fatal 

*  Ebing,  Archiv  fur  Klin.  Med.,  viii. 


778  MEDICAL   DIAGNOSIS. 

coma.  Equally  unpromising  is  early  or  unremitting  delirium. 
When  contrasted  with  the  mental  wandering  in  other  acute  disor- 
ders, the  delirium  of  typhoid  fever  exhibits  peculiar  traits.  It  is 
ordinarily  more  active  than  that  of  typhus ;  far  less  demonstrative 
or  talkative  than  the  mania  of  drunkards ;  as  aimless  as,  but  less 
continued  than,  the  ravings  of  inflammation  of  the  brain.  Great 
restlessness  and  tremors,  associated  with  a  clear  mind,  and  at  times 
with  copious  perspirations,  have  a  very  significant  meaning :  they 
point  to  deep  and  extending  ulceration. 

Other  symptoms  of  grave  disturbance  of  the  nervous  system 
show  themselves  in  violent  general  convulsions.  These  are  more 
common  in  children  than  in  adults,  in  whom  they  may  be  a  late 
symptom  ;  they  may  or  may  not  be  of  ursemic  origin. 

In  some  cases  of  typhoid  fever  symptoms  not  only  of  cerebral 
but  also  of  spinal  origin  appear ;  and  they  may  indeed  assume  a 
high  degree  of  intensity.  We  find  cutaneous  hyperesthesia,  ex- 
tending over  a  large  portion  of  the  body,  spinal  pain  and  tender- 
ness, with  a  sense  of  pricking  along  the  vertebral  column,  and,  in 
some  instances,  cutaneous  and  muscular  ansesthesia,  numbness  of 
the  extremities,  partial  paralysis  or  convulsive  contractions  of  the 
respiratory  muscles,  convulsive  cough,  paralysis  of  the  sphincters, 
contractions  of  the  extremities,  and  even  rigidity  of  the  muscles  of 
the  neck.*  These  spinal  symptoms  are  more  common  when  the 
disease  is  epidemic  than  when  it  is  sporadic,  and  are  always  in- 
dicative of  a  very  serious  form  of  the  disorder.  They  sometimes 
persist  after  the  fever  has  left,  or  indeed — and  this  is  especially 
true  of  paralysis — may  not  appear  until  convalescence.  The  palsy, 
the  most  common  form  of  which  is  paraplegia,  may  or  may  not  be 
linked  to  an  organic  lesion.  It  may  be  preceded  by  trembling 
movements,  suggesting  the  idea  of  disseminated  sclerosis ;  but  the 
tremor  is  rather  the  result  of  general  debility,  and,  unlike  sclerosis, 
it  occurs  before,  and  does  not  attend  or  follow,  the  loss  of  muscu- 
lar power  in  the  limbs,  and  is  not  associated  with  difficulty  of 
enunciation. 

Two  other  prominent  symptoms  of  the  malady  must  still  be 
inquired  into :  one  is  epistaxis ;  the  other,  the  cutaneous  eruption. 

*  Fritz,  Etude  clinique  sur  clivers  Symptomes  spinaux  observes  dans  la 
Fievre  typhoide,  referred  to  in  Arch.  Gen.  de  Med.,  June,  1864. 


FEVERS.  779 

Epistaxis  is  not  often  absent  in  grave  cases.  It  may  happen  at 
any  period  of  the  complaint;  but  it  is  most  apt  to  take  place 
before  the  disorder  is  far  advanced.  The  quantity  of  blood  lost 
is  rarely  considerable ;  and  for  this  reason  the  occurrence  of  the 
hemorrhage  is  frequently  overlooked. 

The  eruption  which  is  peculiar  to  the  disease  is  commonly 
spoken  of  as  the  rose-colored  rash.  It  appears  about  or  shortly 
after  the  seventh  day,  but  occasionally  not  until  the  end  of  the 
second  week.  It  can  hardly  be  called  a  papular  eruption,  as  it 
consists  rather  of  small,  red  spots,  only  very  slightly  elevated 
above  the  skin,  somewhat  similar  to  flea-bites,  yet  differing  from 
them  in  lacking  the  central  mark  and  in  their  finer,  paler  color 
and  less  obvious  outline.  The  spots  are  seen  upon  the  abdomen 
and  chest,  almost  never  upon  the  extremities  or  upon  the  face; 
They  disappear  totally  on  strong  pressure,  yet  return  immediately 
when  the  pressure  ceases.  They  are  generally  few  in  number,  and 
not  persistent.  Each  spot  does  not  last  for  more  than  three  or 
four  days ;  then  it  fades,  and  a  fresh  one  near  by  replaces  it,  and 
runs  the  same  course.  Spots  thus  appear  and  pass  away  for  more 
than  a  week,  after  which,  in  most  cases,  they  entirely  vanish. 
During  convalescence  not  a  trace  of  them  can  be  found;  but 
should  the  patient  get  up  too  soon,  or  be  imprudent  in  his  diet, 
and  a  relapse  take  place,  they  again  show  themselves  wTith  the 
other  symptoms  of  the  malady. 

This  eruption,  although  very  common,  is  not  invariably  pres- 
ent; at  all  events,  it  is  not  invariably  found.  Beyond  doubt, 
too,  it  is  in  some  epidemics  more  constant  and  marked  than  in 
others. 

Late  in  the  disease  another  eruption  appears,  consisting  of  very 
minute  transparent  vesicles,  scattered  plentifully  over  the  body. 
These  sudamina  are  not  so  frequently  encountered  as  the  rose- 
rash,  and  are  certainly  not  characteristic ;  yet  they  are  seen  often 
enough  to  be  regarded  as  a  feature  of  the  affection. 

After  convalescence  has  set  in,  we  may  have  a  return  of 
fever.  It  may  be  either  a  transitory  and  slight  return,  due  to 
fatigue  or  to  some  indiscretion  in  diet,  or  a  more  protracted  state 
in  which  most  or  all  of  the  symptoms  peculiar  to  the  disease  reap- 
pear. These  typhoid  fever  relapses  usually  come  on  in  the  second 
week  of  assured   convalescence,  and,  according  to   my  experi- 


780  MEDICAL    DIAGNOSIS. 

ence,*  occur  suddenly ;  soon'diarrhoea,  furred  tongue,  and  enlarge- 
ment of  the  spleen  are  manifest,  and  on  the  fourth  or  fifth  day  reap- 
pears the  characteristic  rose-rash,  which  is  often  somewhat  coarser 
than  in  the  first  attack,  and  does  not  show  the  same  disposition  to 
appear  in  successive  crops.  With  the  eruption  delirium  is  apt  to 
come  back.  The  temperature  is  unlike  the  original  attack  in  very 
quickly  reaching  a  high  point  of  fever-heat;  after  the  first  day  or 
two  it  remains  more  or  less  stationary  with  a  slight  morning  fall, 
for  five  or  seven  days  usually,  and  then  shows  the  well-known  re- 
missions and  rises  producing  the  zigzag  decline.  The  relapse  is 
in  its  duration  usually  much  shorter  than  the  original  attack, 
and  generally,  notwithstanding  the  threatening  appearance  of  the 
symptoms,  ends  in  convalescence.  During  its  progress  intestinal 
hemorrhage  may  happen ;  and  after  return  to  apparent  health  a 
second  relapse  may  occur.  Each  relapse  of  the  malady  occasions 
characteristic  markings  on  the  nails,  from  impaired  nutrition, 
which  Longstreth  has  very  fully  described.f 

Both  during  the  height  of  the  fever  and  in  convalescence,  but 
more  especially  during  the  latter,  certain  complications  or  sequela? 
may  arise,  some  of  which  are  medical,  such  as  parotitis,  laryngeal 
ulceration,  or  stenosis,  and  milk-leg;  while  others,  as  dislocations, 
caries,  and  necrosis  of  bones  and  gangrene,  come  within  the  domain 
of  surgery.^ 

After  this  analysis  of  the  symptoms  of  typhoid  fever,  it  would 
be  useless  repetition  to  discuss  at  length  how  the  disease  differs 
from  all  other  idiopathic  fevers.  The  attempt  will  rather  be  made 
to  explain  its  diagnosis  from  those  maladies,  whether  essentially 
febrile  or  not,  to  which  it  bears  the  closest  resemblance.  And 
here  we  find  that  the  disorders  with  which  typhoid  fever  may  be  con- 
founded are  not  the  same  at  all  the  stages  of  the  complaint.  Early 
in  the  affection  it  is  most  likely  to  be  mistaken  for  simple  con- 
tinued fever,  or  for  one  of  the  exanthemata.  But  diarrhcea  is  not 
present  in  these,  nor  are  there  marked  prodromata ;  and  whatever 
doubt  may  exist  with  reference  to  simple  continued  fever  is  cleared 

*  See  article  on  Kelapses  of  Typhoid  Fever,  Transactions  of  the  College  of 
Physicians  of  Philadelphia,  1877. 

f  Ibid.,  1877. 

X  See  an  elaborate  discussion  of  these  surgical  complications,  by  Dr.  "W. 
W.  Keen,  Fifth  Toner  Lecture,  Washington,  1877. 


FEVEES.  781 

up  in  a  few  days,  as  the  temperature-record  is  different  and  as  the 
symptoms  come  to  an  end  at  a  time  at  which  in  typhoid  fever  they 
begin  to  be  more  and  more  developed.  Still,  the  exanthematous 
fevers  cannot,  before  their  eruptions  appear,  be  distinguished  with 
absolute  certainty;  though  we  may  suspect  measles  by  the  at- 
tending coryza,  scarlatina  by  the  sore  throat,  and  smallpox  by  the 
lumbar  pains  and  high  fever. 

At  a  more  advanced  period,  typhoid  fever  may  be  confounded 
with  typhus,  and  with  these  morbid  states  : 

General,  Debility  ; 

Typhoid  Conditions; 

Enteritis  ; 

Peritonitis  ; 

Meningitis  ; 

Acute  Pulmonary  Affections. 

General  Debility. — It  does  not  at  first  sight  seem  likely  that  so 
acute  and  dangerous  a  malady  as  typhoid  fever  could  be  mistaken 
for  mere  debility ;  yet  such  an  error  may  occur  where  the  disease 
is  latent,  or  so  light  as  hardly  to  confine  the  patient  to  his  bed. 
In  these  so-called  "  walking  cases"  of  the  fever,  the  debility,  how- 
ever, sets  in  suddenly,  and  not  gradually,  as  in  weakness  from 
general  constitutional  causes.  Moreover,  the  abdominal  symptoms 
are  rarely  wanting,  and  there  is  always  more  or  less  confusion  of 
mind.  Due  attention  to  these  circumstances  will  prevent  mis- 
take ;  but  the  greatest  safeguard  against  error  is  to  be  aware  that 
the  disease  assumes  at  times  a  latent  form,  and  to  examine  every 
case  of  great  and  sudden  debility,  to  see  if  under  its  mask  are 
hidden  the  features  of  typhoid  fever. 

Typhoid  Conditions. — No  blunder  is  more  common  than  to  mis- 
construe into  typhoid  fever  a  typhoid  condition  of  the  system. 
We  may  find  this  condition  in  many  different  complaints,  both 
acute  and  chronic;  but  more  especially  are  purulent  infection, 
some  forms  of  pneumonia,  dysentery,  and  erysipelas  attended  with 
delirium,  drowsiness,  dry,  brown  tongue,  and  extreme  prostration, 
— in  one  word,  with  a  typhoid  state. 

Yet  a  typhoid  state  is  not  typhoid  fever ;  it  is  simply  a  low 
condition  of  the  system  which  may  be  present  in  many  dissimilar 
maladies,  and  which  is  present  in  its  most  perfect  form  in  typhoid 
fever.     But  in  this  malign  complaint  we  have  other  signs  than 


782  MEDICAL    DIAGNOSIS. 

those  of  vital  depression :  we  find  joined  to  it  diarrhoea,  tympa- 
nites, epistaxis,  an  eruption,  and  special  manifestations  of  dis- 
turbance of  the  nervous  system, — all  symptoms  bearing  no  direct 
relation  to  the  adynamia,  and  thus  serving  as  valuable  distinctive 
marks.  An  examination  of  the  urine,  too,  is  often  of  signal  ser- 
vice, though  we  must  not  forget  that  in  grave  cases  albuminuria 
to  a  moderate  degree  is  present.  And  there  are  cases  of  Bright's 
disease  and  of  abscess  of  the  kidney  in  which  the  poisoning  of  the 
blood  which  happens  occasions  a  deceptive  likeness  to  typhoid 
fever, — so  deceptive  that  only  a  minute  examination  of  the  urine 
can  fully  explain  the  true  meaning  of  the  symptoms.  The  fol- 
lowing case  well  illustrates  this  : 

A  man,  about  forty-five  years  of  age,  was  admitted  into  the 
Philadelphia  Hospital  in  January,  1863.  He  was  very  prostrate, 
and  hardly  able  to  give  an  account  of  himself.  It  was,  however, 
ascertained  that  he  was  not  a  person  of  intemperate  habits,  and 
that  he  had  been  attending  to  his  work  until  within  two  weeks. 
He  was  evidently  stupid,  and,  when  questioned  about  himself, 
seemed  to  have  great  difficulty  in  remembering,  and  in  collecting 
his  thoughts.  He  had  fever ;  a  pulse  above  100 ;  a  dry,  brown 
tongue.  The  heart-sounds  were  feeble,  the  heart  increased  in  size. 
The  urine  was  at  times  turbid,  and  contained  a  slight,  whitish 
sediment,  which  was  not,  however,  examined  with  the  micro- 
scope. His  mind  wandered  at  night ;  the  abdomen  was  distended 
and  in  parts  slightly  tender;  several  doubtful  red  spots  were  de- 
tected on  its  surface.  In  fact,  he  appeared  to  have  almost  every 
one  of  the  more  constant  symptoms  of  typhoid  fever,  except  the 
diarrhoea.  A  few  days  after  his  admission  he  became  comatose, 
and  sank.  The  intestinal  glands  were  found  in  a  healthy  condi- 
tion ;  but  both  kidneys  were  thoroughly  disorganized  and  filled 
with  pus. 

What  exactly  produces  the  typhoid  state  it  is  difficult  to  say. 
In  an  instructive  essay,  Milner  Fothergill*  connects  it  with  tissue- 
waste  without  increased  renal  activity,  and  with  the  accumulation 
in  the  blood  of  the  products  of  the  tissue-waste. 

Enteritis. — The  great  difference  between  enteritis  and  typhoid 
fever  consists  in  this:  in  enteritis  the  inflammation  of  the  intes- 

*  Edinburgh  Medical  Journal,  September,  1873. 


FEVERS.  783 

tine  constitutes  the  disease ;  in  typhoid  fever  the  irritation  of  the 
intestine  and  morbid  alteration  of  its  glands  are  merely  elements 
of  the  disease.  In  enteritis,  therefore,  there  are  no  further  symp- 
toms than  those  referable  to  the  inflamed  intestine.  We  find  no 
great  prostration ;  no  mental  wandering ;  no  enlargement  of  the 
spleen ;  no  rose-spots  and  sudamina ;  no  signs  of  abnormal  pro- 
cesses due  to  a  typhoid  dyscrasia.  The  disorder,  too,  gives  rise  to 
much  more  abdominal  pain,  and  is  of  shorter  duration.  In  certain 
rare  cases  the  follicles  of  the  intestines  are  inflamed  and  swollen, 
and  the  attending  febrile  malady  may  closely  simulate  typhoid  fever, 
without,  however,  its  characteristic  intestinal  lesions,  or  eruption, 
though  with  considerable  diarrhoea  and  swelling  of  the  spleen.* 

Peritonitis. — The  same  remarks  apply  to  peritoneal  inflamma- 
tion. Here,  moreover,  the  expression  of  the  face,  the  constipation, 
and  the  great  abdominal  tenderness  serve  as  marks  of  discrimi- 
nation. But  we  must  not  forget  that  acute  inflammation  of  the 
peritoneum  may  appear  in  the  course  of  typhoid  fever.  Generally 
this  untoward  event  happens  at  a  late  period  of  the  disease,  and 
after  the  patient  has  been  under  observation  for  some  time ;  we 
are  then  at  no  loss  to  understand  the  meaning  of  the  spreading 
tenderness,  the  rapid,  small  pulse,  the  marked  tympanitic  disten- 
tion, the  sweats,  the  nausea  and  vomiting,  the  collapse,  and  the 
pinched  features.  But  the  accident  may  occur  in  cases  which  we 
have  not  previously  seen,  or  in  which  the  affection  has  run  so 
latent  a  course  as  hardly  to  have  attracted  even  the  patient's 
attention.  The  cause  of  the  peritonitis  is  then  commonly  first 
revealed  by  the  autopsy,  which  shows  actual  perforation  of  the 
intestinal  walls,  in  consequence  of  ulceration  of  a  solitary  or  an 
agminated  gland.  Whenever,  indeed,  in  typhoid  fever  the  signs 
of  peritonitis  can  be  clearly  traced,  the  exciting  cause  of  the 
inflammation  may  be  announced  to  be  perforation  ;  for  the  evi- 
dence on  which  it  has  been  assumed  that  peritoneal  inflammation 
may  take  place  without  the  giving  way  of  the  intestine  is  not  so 
positive  as  to  cause  us  to  abandon  this  diagnostic  rule. 

Meningitis. — Typhoid  fever  has  some  symptoms  in  common 
with  inflammation  of  the  brain ;  but  the  signs  of  difference  have 
been  fully  discussed  in  connection  with  acute  meningitis,  and  need 

*  Cazalis  and  Eenaut,  Archives  de  Physiologie,  1873. 


784  MEDICAL    DIAGNOSIS. 

not  here  be  examined.  The  distinction  from  epidemic  cerebro- 
spinal meningitis  we  shall  presently  trace. 

Acute  Pulmonary  Affections. — In  the  majority  of  cases  of  typhoid 
fever  we  find  cough,  dependent  upon  an  affection  of  the  bronchial 
tubes.  The  bronchial  affection  gives  rise  to  extreme  loudness  of 
the  rales,  with  a  cough  disproportionately  slight;  sometimes,  too, 
owing  to  the  blood  gravitating  to  the  most  dependent  portions 
of  the  lungs,  the  resonance  over  the  posterior  part  of  the  chest  is 
impaired.  From  these  phenomena,  added  to  the  abdominal  and 
cerebral  symptoms  of  the  fever,  there  is  no  difficulty  in  discrimi- 
nating between  idiopathic  bronchitis  and  typhoid  fever.  Nay, 
even  before  the  symptoms  of  the  febrile  malady  are  clearly  de- 
fined, we  may  suspect  the  true  explanation  of  the  rales  from  the 
coexisting  extreme  vital  depression. 

Xot  unfrequently  we  find  a  dry  pleurisy  combined  with  the 
bronchitis,  and  in  some  cases,  not  in  many,  the  cough  is  asso- 
ciated with  exudation  into  the  pulmonary  structure.  Xow,  it 
may  be  extremely  difficult  to  distinguish  a  pulmonic  lesion  of 
this  kind  from  inflammation  of  the  lung  setting  in  amid  signs 
of  prostration,  until  the  appearance  of  the  eruption  and  of  the 
abdominal  symptoms  solves  the  difficulty.  Generally,  however, 
it  is  not  a  matter  of  much  doubt,  as  the  condensation  of  the  lung 
in  typhoid  fever  does  not  occur  early  in  the  disease, — not,  in  fact, 
until  the  symptoms  of  the  fever  are  clearly  developed.  Occasion- 
ally a  cough  remains  after  the  febrile  symptoms  have  begun  to 
decline  and  the  mind  is  regaining  its  clearness.  The  cough  in- 
creases in  severity,  and  the  patient  soon  loses  the  strength  he  may 
have  acquired.  On  listening  to  the  chest,  we  find  scattered  over 
both  lungs  many  fine,  dry  and  moist  sounds.  The  percussion 
note  is  here  and  there  dull ;  the  expectoration  is  profuse ;  there 
are  dyspnoea  and  excessive  sweating.  Here  is  a  group  of  signs 
which  if  not  absolutely  are  at  least  almost  invariably  associated 
with  the  occurrence  of  acute  tubercular  phthisis.  The  further 
progress  of  the  disease  reveals  its  nature  more  and  more  dis- 
tinctly, and  many  of  the  symptoms  of  the  typhoid  state  reappear. 
But  there  is  no  difficulty  in  establishing  the  fact  that  the  formida- 
ble complication  followed,  or  was  at  least  fanned  into  life  by,  the 
attack  of  fever.  Sometimes,  however,  we  observe  acute  phthisis 
with  most  of  the  symptoms  of  typhoid  fever  without  that  affec- 


FEVERS.  785 

tion  being  before  us;  even  the  delirium,  the  stupor,  and  the  en- 
largement of  the  spleen  may  be  present;  but  the  eruption  never 
is,  and  the  diarrhoea  rarely. 

In  concluding  the  subject  of  typhoid  fever  it  will  be  proper 
to  notice  those  forms  of  the  affection  which  run  their  course  in 
a  different  manner  from  that  ordinarily  pursued  by  the  malady. 
Such  forms,  for  instance,  are  the  mild  typhoid  and  the  abortive 
typhoid.  The  former  has  usually  a  gradual  beginning,  and  the  dis- 
ease throughout  remains  mild ;  its  duration  may  be,  however,  the 
same  as,  or  even  longer  than,  that  of  ordinary  typhoid,  or  it  may 
be  considerably  shorter,  in  fact  an  abortive  typhoid,  the  variety  of 
typhoid  to  which  of  late  years  Jurgensen  especially  has  directed 
attention.*  Yet  the  abortive  type  is  not  always  mild:  cases  are 
mentionedf  in  which  the  temperature  rose  to  106°,  but  in  which 
the  duration  of  the  fever  was  only  from  seven  to  twelve  days. 
Indeed,  it  is  the  short  duration  that  is  characteristic  of  abortive 
typhoid.  As  a  rule,  it  begins  suddenly,  and  the  temperature 
reaches  its  highest  point  on  the  second  or  third  day.  It  often  does 
not  exceed  104°,  and  it  stays  at,  or  near,  the  height  it  has  so 
speedily  attained  for  the  greater  part  of  the  duration  of  the  fever, 
and  then  remissions  show  themselves,  and  there  is  a  gradual  return 
to  a  healthy  standard,  much  in  the  same  way  as  at  the  end  of 
ordinary  typhoid  fever ;  or  the  changes  are  so  marked  and  rapid 
that  the  defervescence  is  accomplished  in  a  few  days.  The  symp- 
toms of  typhoid  fever  are  all  met  with  in  the  abortive  malady, 
though  they  are  not  present  with  the  same  constancy ;  tenderness 
in  the  right  iliac  fossa  is  the  most  frequent;  enlargement  of  the 
spleen  and  the  rose-colored  spots  are  very  usual ;  diarrhoea  is 
often  wanting.  The  disease  terminates  in  sixteen  days  or  less ; 
but  there  is  great  proneness  to  relapses.  It  is  not  apt  to  be  a 
fatal  affection. 

Typhus  Fever. — The  term  typhus  is  not  very  definite  in  its 
signification.  The  German,  Swedish,  Irish,  and  some  of  the 
British  physicians  comprise  under  it  all  low  forms  of  fever,  in- 
cluding typhoid.      In  this  country  and  in  France  it  is  applied 


*  Sammlung  Klinischer  Vortrage,  No.  61,  1873  ;  see  also  a  paper  by  John- 
ston, Amer.  Journ.  of  Med.  Sci.,  Oct.  1875. 
f  Liebermeister,  in  Ziemssen's  Cyclopaedia. 

50 


786  MEDICAL    DIAGNOSIS. 

solely  to  that  low,  continued  fever  prevailing  in  jails  and  camp?, 
among  crowded  populations,  or  in  badly-ventilated  localities,  and 
which  is  not  characterized  by  any  constant  structural  lesion. 
Without  entering  into  the  discussion  whether  it  be  nothing  but  a 
cerebral  form  of  that  same  typhous  disorder  of  which  typhoid  is 
regarded  as  the  abdominal  form,  we  cannot  but  recognize  in  it 
many  phenomena  so  different  from  those  of  typhoid  or  enteric 
fever  that  on  clinical  grounds  alone,  if  on  no  others,  a  separate 
recognition  is  called  for. 

Typhus  fever  is  a  highly  contagious  malady,  almost  always  met 
with  in  an  epidemic  form,  and  generally  among  those  whose  sys- 
tems are  depressed  or  whose  blood  is  impoverished.  It  is  either 
preceded  by  a  brief  stage  of  lassitude  and  dejection,  or  is  ushered 
in  with  a  chill  and  pain  in  the  head  and  back.  The  skin  soon 
becomes  dry  and  of  pungent  heat;  the  pulse  rises  much  in  fre- 
quency, and  is  at  first  full,  sometimes  even  tense.  The  patient 
lies  in  a  state  of  half-consciousness ;  very  dull,  very  drowsy,  very 
weak,  with  evident  signs  of  his  nervous  and  muscular  system  being 
overwhelmed  by  the  influence  of  some  fearfully  depressing  poison. 
The  face  is  flushed;  the  eye  injected;  the  odor  from  the  body 
extremely  unpleasant. 

By  the  fifth  day  all  these  symptoms  are  plainly  marked,  and 
about  this  time  a  coarse,  red,  cutaneous  eruption  makes  its  appear- 
ance. But  it  occasions  no  change  in  the  gravity  of  the  symptoms. 
On  the  contrary,  the  confusion  of  mind  and  the  stupor  increase; 
the  patient  wanders,  picks  at  his  bedclothes,  and  ceases  to  com- 
plain of  the  pain  in  the  head  or  limbs.  The  pulse  is  frequent  and 
feeble ;  the  tongue  dry  and  dark ;  sordes  collect  on  the  gums  and 
teeth.  The  bowels  remain  as  they  were  at  the  onset, — constipated. 
The  urine  often  comes  away  drop  by  drop,  or,  as  the  bladder 
loses  the  power  of  contracting,  is  retained.  The  case  has  now 
reached  its  height;  the  signs  of  a  prostrated  nervous  system,  of 
deteriorated  blood,  and  of  utter  loss  of  muscular  strength  either 
begin  to  pass  away,  or  deepen  from  hour  to  hour  and  clearly 
show  the  doom  that  awaits  the  fever-stricken  patient.  From  the 
beginning  of  the  distemper  until  the  unfortunate  issue,  is  rarely 
over  thirteen  days.  If  the  sick  man  can  withstand  the  poison 
until  the  third  week,  he  is  apt  to  throw  it  off  and  recover;  but 
it  may  be  so  virulent  as  to  overpower  him  almost  at  the  onset. 


FEVERS.  787 

Let  us  examine  some  of  the  symptoms  of  this  pestilential  dis- 
ease in  detail. 

The  physiognomy  of  typhus  is  peculiar.  The  expression  is 
stupid,  and  coarser  than  in  health.  The  face  wears  a  deep  flush, 
of  a  dusky-red  hue.  The  eye  is  injected,  the  pupil  often  con^ 
tracted.  The  skin  is  covered  with  a  characteristic  eruption,  from 
which  the  disease  takes  its  name  of  "  spotted"  or  "  maculated" 
typhus.  The  rash  is  well  defined,  at  first  slightly  elevated  and 
usually  much  like  that  of  measles.  It  is  of  a  dark  tint,  and  fades 
but  does  not  vanish  on  pressure.  It  makes  its  appearance  from 
the  fifth  to  the  seventh  day,  and  is  permanent,  consisting  not  of 
successive  eruptions,  but  of  the  same  spots,  which  deepen  or 
lighten  with  the  changes  in  the  disease,  and  do  not  pass  away 
before  the  fourteenth  day.  Each  spot  thus  lasts  until  recovery  or 
until  death,  and  no  new  ones  show  themselves  after  the  second  or 
third  day  of  the  rash.  They  are  generally  very  numerous  on  the 
trunk  and  the  extremities,  but  are  rarely  observed  upon  the  face. 
Some  are  much  lighter  than  others,  and  thus  a  mottled  aspect  of 
the  skin  is  produced,  on  which  Sir  William  Jenner* — who  has 
described  the  typhus-fever  eruption,  or,  as  he  calls  it,  the  "  mul- 
berry rash,"  with  much  fidelity — lays  great  stress.  Sometimes 
the  spots  are  of  purple  color  and  uninfluenced  by  pressure.  These 
petechia?  are  the  attendants  of  the  worst  forms  of  the  malady. 

The  different  forms  of  eruption,  however,  are  different  in  de- 
gree rather  than  in  kind.  The  poison  leads  to  local  interference 
in  the  capillary  circulation,  and  then  to  transudation  from  and 
rupture  of  the  distended  vessels;  and  it  may  do  this  partly  in 
consequence  of  the  vitiation  of  the  blood,  partly  by  its  action  on 
the  sympathetic  nervous  system.  This,  it  is  likely,  is  the  cause  of 
the  eruption,  and  the  extent  and  consequences  of  the  paralysis  of 
the  capillaries  explain  the  more  or  less  obvious  effect  of  pressure 
on  the  rash  in  many  idiopathic  fevers. 

The  skin  of  a  typhus  fever  patient  is  often  sensitive,  and,  as 
already  stated,  generally  very  hot.  In  some  cases  the  thermometer 
indicates  a  temperature  of  107°,  or  more ;  most  commonly  it  ranges 
above  104°.     The  heat  is  sustained  :  it  does  not  show  the  marked 


*  Identity  or  Non-Identity  of  Typhoid  and  Typhus  Fevers,.  London,.  1850; 
and  Medico-Chirurgical  Transactions,  vol.  zxxiii. 


788  MEDICAL    DIAGNOSIS. 

differences  between  morning  and  evening  which  are  observed  in 
typhoid  fever;  the  daily  variations  to  the  middle  of  the  second 
week  being  rarely  1°  Fahr. ;  and  from  that  time  onward  the 
morning  abatement  does  not  amount  to  more  than  about  1.5°, 
until  the  defervescence  is  reached.  The  passing  away  of  the  high 
temperature  occurs,  however,  not,  as  in  the  enteric  fever,  by 
gradual  though  more  and  more  evident  remissions,  but  suddenly. 
Early  in  or  toward  the  middle  of  the  third  week  the  temperature 
falls  quickly,  and  in  twenty-four  or  thirty-six  hours  a  normal 
standard  is  reached. 

The  cerebral  symptoms  of  typhus  fever  are  never  absent,  al- 
though they  vary  much  both  in  intensity  and  in  character.  In 
some  epidemics  they  constitute  the  prominent  feature  of  many 
cases,  and  dangerous  and  fatal  these  cases  are  apt  to  be.  One  of 
the  most  frequent  proofs  of  the  disturbance  of  the  brain  is  seen 
in  stupor.  The  patient's  mind  seems  gone:  he  lies  in  a  heavy 
slumber,  occasionally  muttering  some  incoherent  words ;  or  he  is 
sleepless,  his  eyes  remain  wide  open,  yet  he  takes  no  notice  of  any- 
thing going  on  around  him.  Either  of  these  states  may  deepen 
into  coma. 

In  other  cases  delirium  is  the  most  conspicuous  symptom.  Now, 
this  delirium  rarely  sets  in  before  the  end  of  the  first  week,  though 
it  may  precede  the  eruption.  In  type  it  is  low  and  muttering, 
and  unaccompanied  by  great  restlessness ;  or  it  may  be  associated 
with  constant  movements  and  trembling  of  the  limbs,  or  jerking 
of  the  tendons, — in  fact,  with  symptoms  resembling  those  desig- 
nated as  hysterical.  Sometimes  the  mental  wandering  is  active 
and  very  persistent.  The  patient  tosses  about,  is  constantly  talk- 
ing, and  can  hardly  be  restrained  from  getting  out  of  bed.  He 
has  illusions  of  hearing  and  of  sight;  his  eyes  are  injected,  the 
pupils  often  contracted ;  there  is  headache,  with  intolerance  of 
light.  Here  we  have  the  true  brain  typhus,  with  its  formidable 
cerebral  symptoms  simulating  closely  those  of  idiopathic  inflam- 
mation of  the  membranes  of  the  brain,  and  differing  only  by  their 
union  with  a  cutaneous  eruption,  by  the  dissimilar  aspect  of  the 
tongue,  and  by  the  beat  of  the  pulse,  which  is  rarely  very  full, 
and  never  so  tense  as  that  of  meningitis.  Then,  the  nervous 
excitement  is  accompanied  or,  at  all  events,  soon  succeeded  by 
greater  and  more  rapid  prostration  of  strength,  and  is  often  ex- 


FEVERS.  789 

changed  far   more   suddenly  for  coma  than   is   observed  in  the 
meningeal  disorder. 

The  headache  which  has  just  been  alluded  to  is  a  very  constant 
symptom :  usually  it  is  most  severe  during  the  first  week,  and 
abates  with  the  appearance  of  the  mental  wandering.  Often  it  is 
accompanied  by  more  or  less  giddiness,  which  increases  with  the 
progress  of  the  disease. 

The  cause  of  the  violent  disturbance  of  the  brain  is  due  either 
to  the  direct  effect  of  the  poison  on  this  nervous  centre,  or  to  the 
impure  blood  which  circulates  through  it;  the  vehement  symp- 
toms may  coincide  with  a  mere  congestion, — nay,  even  a  brain  and 
spinal  marrow  presenting,  to  all  appearances,  a  perfectly  healthy 
structure. 

These  head-symptoms  of  typhus  are,  like  those  of  enteric  fever, 
sometimes  connected  with  a  noisy,  shallow,  and  irregular  respira- 
tion. This  kind  of  breathing  can  be  clearly  traced  to  the  abnormal 
state  of  the  nervous  system,  as  no  signs  of  alteration  in  the  lungs 
coexist.  Often,  as  Flint*  has  lucidly  pointed  out,  it  is  a  fore- 
runner of  fatal  coma.  In  one  case  I  found  the  strange  phenome- 
non associated  with  great  distention  of  the  bladder,  and  subsiding 
materially  after  the  introduction  of  a  catheter. 

The  remarks  made  with  reference  to  the  cerebral  phenomena 
of  typhus  apply  to  those  instances  in  which  there  is  no  inflam- 
matory disorder  within  the  cranium.  But  we  must  not  overlook 
the  fact  that  this  may  ensue.  Such  cases  are  difficult  of  recog- 
nition. The  pulse,  as  a  rule,  is  slow  and  irregular,  the  pupils 
are  contracted,  there  is  a  frown  on  the  forehead,  and  intense  head- 
ache, sometimes  screaming.  Vomiting  is  not  always  encountered. 
We  may  find  with  these  symptoms  acute  hydrocephalus,  and  the 
morbid  appearances  may  be  confined  chiefly  to  the  base  of  the 
brain,  f 

There  are  other  symptoms  referable  to  the  nervous  system 
which  are  occasionally  very  marked,  such  as  great  agitation, 
rigidity  of  certain  muscles,  and  convulsions.  But  as  regards  the 
latter,  the  nervous  system  is  for  the  most  part  only  secondarily 
disturbed,  for  the  convulsions  are  generally  of  ursemic  origin. 

*  Clinical  Reports  on  Continued  Fever. 

f  Kennedy,  Dublin  Quarterly  Journal,  Feb.  1867. 


790  MEDICAL    DIAGNOSIS. 

The  circulation  in  typhus  exhibits  some  peculiarities  worthy  of 
note.  The  pulse,  after  the  disease  is  fully  developed,  is  generally 
rapid,  and  either  of  moderate  volume  or  feeble.  As  the  disorder 
advances,  and  the  strength  becomes  more  and  more  impaired,  it 
rises  in  frequency,  while  it  diminishes  in  force.  As  convalescence 
is  established,  it  falls;  if  it  remain  frequent,  this  is  generally 
indicative  of  some  concealed  visceral  disorder,  often  of  a  disease 
of  the  lungs.  It  does  not  always  correspond  closely  with  the 
condition  of  the  heart,  so  far,  at  least,  as  this  is  revealed  by  the 
impulse.  The  beat  may  be  excited  and  violent,  while  the  pulse 
is  very  weak.  At  times  the  cardiac  impulse  undergoes  a  singular 
diminution,  and  with  its  change  the  first  sound  becomes  enfeebled  ; 
in  fact,  it  is  sometimes  almost  lost,  and  only  very  gradually  re- 
gains its  natural  tone.  Occasionally,  at  the  height  of  the  disease, 
it  is  replaced  by  a  soft,  systolic  murmur;  not  here  a  sign  of  in- 
flammation, but  dependent  upon  the  depraved  state  of  the  blood. 
The  sphygmograph  may  show  an  improvement  in  the  pulse  by 
demonstrating  a  slight  return  of  its  dicrotism  before  any  improve- 
ment can  be  ascertained  by  the  finger.* 

The  urine  is  generally  high-colored  at  first,  but  may  become 
very  pale  as  convalescence  sets  in,  depositing  an  abundance  of 
urates  and  phosphates.  There  is  an  absence  of  the  chlorides,  or 
they  are  reduced  to  a  trace.  The  urea,  as  ascertained  by  an 
analysis  of  Parkesf  in  a  case  in  which  no  medicine  was  given, 
is  increased,  and  its  augmented  excretion  is  remarkably  regular 
during  the  height  of  the  malady.  Indeed,  the  increased  amount 
of  urea  is,  as  determined  by  repeated  examinations  of  the  urine 
of  typhus  fever,  very  constant,  and  is  a  proof  of  the  more  active 
metamorphosis  of  tissue.  During  convalescence  the  urea  sinks 
below  the  physiological  standard,  and  then  gradually  rises  to  it. 
These  observations,  however,  must  be  compared  with  those  of 
Rosenstein,  to  which  we  have  referred  when  discussing  the  chem- 
istry of  urea. 

Notwithstanding  the  amount  of  water  drunk,  the  water  passed 
is  lessened,  and  it  would  appear  to  be  retained  in  the  system. 
The  urine  is  apt  to  contain  a  large  amount  of  uric  acid,  and,  as  a 


*  Dublin  Quarterly  Journal,  Feb.  1867. 
f  The  Urine  in  Disease,  p.  258. 


FEVERS.  791 

rule,  preserves  its  acidity.  In  8  out  of  21  cases  that  I  examined 
during  an  epidemic,*  it  contained  albumen,  and  this  ingredient 
was  present  only  in  the  severer  cases.  In  some  instances  the 
microscope  exhibits  in  the  deposit,  besides  the  salts  of  the  urine, 
renal  as  well  as  vesical  epithelium,  and  tube-casts,  either  finely 
granular  or  hyaline,  or  epithelial.  Very  much  the  same  condi- 
tion of  urine,  as  regards  most  of  the  constituents,  is  also  found  in 
typhoid  fever.  But  the  pigment  which  in  typhus  fever  was  de- 
tected by  Parkes  throughout  only  in  small  amounts,  has  in  typhoid 
fever  been  found  to  be  immensely  increased. 

The  complications  encountered  during  the  course  of  the  fever, 
or  during  convalescence,  are  much  the  same  as  those  of  typhoid 
fever,  although  they  do  not  in  the  two  diseases  occur  with  equal 
frequency.  We  meet  with  abscesses,  with  large  sloughs  on  the 
trunk  and  extremities,  or  with  gangrene  of  the  extremities,!  with 
milk-leg,  with  erysipelas,  with  inflammation  of  the  parotid  gland, 
with  oedema  of  the  glottis,  and  with  pulmonary  complaints.  The 
latter  are  very  common,  and  mostly  very  alarming.  Sometimes 
they  consist  merely  in  affections  of  the  larger  bronchial  tubes; 
but  very  often  we  have  to  deal  with  a  dangerous  capillary  form 
of  bronchitis,  beginning  insidiously,  not  attended  with  much 
cough,  and  easily  overlooked.  A  coarse  crepitation  or  fine  bub- 
bling sounds  are  heard  over  the  whole  chest,  and  the  respiration 
is  hurried.  At  times,  instead  of  these  signs,  or  associated  with 
them,  may  be  noticed  dulness  on  percussion  and  bronchial  respira- 
tion over  the  lower  lobes  of  the  lungs,  depending  upon  conges- 
tion, with  consolidation  more  or  less  perfect,  of  the  pulmonary 
tissue.  Here  is  one  of  the  worst  of  all  the  complications, — a  low 
form  of  pneumonia.  During  the  last  stages  of  the  fever,  or  after 
convalescence  has  set  in,  acute  tubercular  deposits  occasionally 
develop  themselves  in  the  lungs  with  the  same  symptoms  as 
during  or  subsequent  to  typhoid  fever.  One  of  the  most  sig- 
nificant signs  of  this  untoward  event  is  the  utter  want  of  response 
of  the  system  to  stimulants  and  tonics. 

To  discuss  now  the  differential  diagnosis  of  typhus  fever.  We 
find  various  maladies  resembling  it,  but  none  so  closely  as  typhoid 

*  Amer.  Journ.  of  Med.  Sci.,  Jan.  1866. 

f  Estlander,  quoted  in  Amer.  Journ.  of  Med.  Sci.,  July,  1871. 


792 


MEDICAL    DIAGNOSIS. 


fever.    The  subjoined  table  shows  both  their  similarities  and  their 
differences : 


Typhoid. 

Age  generally  from  eighteen  to  thirty- 
five. 

Not  contagious,  or  but  feebly  so ; 
often  sporadic. 

Attack  generally  insidious. 

Duration  fully  three  weeks ;  very 
frequently  much  longer. 

Death  hardly  ever  before  end  of  sec- 
ond week  ;  more  generally  in,  or 
after,  third  week. 

Cerebral  symptoms  come  on  gradu- 
ally ;  last  longer. 


Great  emaciation. 

Face  pale,  or  flush  confined  to  cheeks. 

Skin  hot,  sometimes  covered  with 
acid  perspiration. 

Abdominal  symptoms,  such  as  diar- 
rhoea, tympanites;  intestinal  hem- 
orrhage not  unusual. 


Epistaxis  common. 
Bronchitis  and  pleurisy. 


Eruption  light  red,  and  not  on  ex- 
tremities. 

Post-mortem  appearances  are :  mor- 
bid state  of  Peyer's  patches ;  en- 
largement of  mesenteric  glands ; 
ulceration  of  mucous  coat  of  intes- 
tine ;  enlargement  and  softening  of 
spleen  ;  ulceration  of  pharynx. 


Typhus. 

At  all  ages ;  often  in  persons  beyond 
middle  life. 

Highly  contagious ;  generally  epi- 
demic. 

Attack  generally  sudden  ;  no  length- 
ened prodromata. 

Duration  somewhat  shorter ;  often  not 
prolonged  beyond  second  week. 

Death  not  unfrequently  at  end  of  first 
week,  and  often  before  conclusion 
of  second. 

Delirium  or  decided  stupor  comes  on 
soon,  sometimes  almost  from  the 
onset ;  headache  has  appeared  and 
disappeared  by  about  the  tenth  day. 

Less  emaciation  ;  greater  prostration. 

Face  deeply  flushed,  of  dusky  hue; 
eye  injected. 

Skin  of  pungent  heat ;  sometimes 
emitting  an  ammoniacal  odor. 

No  abdominal  symptoms ;  bowels  con- 
stipated ;  meteorism  rare ;  intes- 
tinal hemorrhage  extremely  rare, 
if  it  ever  occur;  sometimes  acute 
dysentery  during  convalescence,  or 
as  a  sequel. 

No  epistaxis. 

Pneumonia,  or,  at  all  events,  more 
marked  intense  congestion  of  the 
lungs,  and  bronchitis  of  finer  tubes. 

Eruption  darker  color,  and  all  over 
body. 

No  constant  post-mortem  appear- 
ances ;  the  most  frequent  are  the 
dark- colored,  liquid  state  of  the 
blood,  and  enlargement  of  spleen. 
Softening  of  the  heart  is  more 
common  in  typhus  than  in  typhoid. 
There  are  no  intestinal  lesions. 


•  The  points  of  contrast  between  the  two  affections  are  here  so 
manifest  that  it  would  seem  impossible  ever  to  confound  them. 
Yet  it  must  be  remembered  that  all  the  signs  are  not  present  in 


FEVERS.  793 

every  case.  Nor  does  this  table  go  to.  prove  anything  beyond  the 
clinical  distinction  between  the  kindred  maladies;  certainly  not 
a  different  cause  of  production,  or  a  dissimilar  nature.  Neither 
can  it  be  denied  that  occasionally  the  symptoms  of  the  two  dis- 
eases are  strangely  blended  or  interchanged.  Thus,  we  may  have 
constipation  in  typhoid,  and  diarrhoea  in  typhus,  or  the  eruption 
may  be  curiously  mixed.     For  instance: 

A  boy,  sixteen  years  of  age,  was  received  into  the  Philadelphia 
Hospital,  with  evident  signs  of  a  beginning  fever  of  a  low  type. 
A  day  or  two  after  his  admission,  and  corresponding,  as  nearly  as 
could  be  ascertained,  to  the  fifth  day  of  the  disease,  an  eruption 
showed  itself  all  over  the  body.  It  was  dark-colored,  petechial 
in  its  aspect,  and  did  not  disappear  on  pressure.  Associated  with 
it  were  drowsiness  and  constipation.  In  a  few  days  more,  how- 
ever, the  symptoms  changed.  The  dark  eruption  faded,  and  rose- 
colored  spots  were  perceptible  on  the  chest  and  abdomen  ;  diarrhoea 
set  in,  and  the  fever  ran  its  course  to  a  favorable  termination  with 
the  character  of  typhoid,  just  as  at  the  onset  it  had  assumed  the 
character  of  typhus. 

Besides  typhoid  fever,  typhus  may  be  confounded  with  menin- 
gitis, with  inflammation  of  the  lungs,  with  measles,  with  small- 
pox, and  with  the  plague.  The  distinctive  marks  between  the 
first  two  and  typhus  fever  have  been  rendered  apparent  Avhile 
discussing  the  cerebral  and  pulmonary  complications  of  the  latter 
malady.  I  shall  here  only  dwell  again  upon  the  great  value  of 
the  eruption  in  a  diagnostic  point  of  view.  The  symptoms  which 
approximate  measles,  smallpox,  and  yellow  fever  to  typhus  will 
be  analyzed  in  connection  with  these  affections.  One  word  here 
as  to  its  difference  from  the  plague. 

This  pestilent  disease,  which  during  several  centuries  left  almost 
annually  its  deep  indent  upon  the  human  race,  is  hardly  known 
to  any  but  Russian  physicians  at  present,  save  by  description.  And 
the  descriptions  'leave  on  the  mind  the  impression  of  an  exposition 
of  a  familiar  malady ;  for  the  authors  who  have  most  carefully  de- 
lineated its  traits  have  produced  a  picture  which,  with  very  slight 
changes,  may  be  suited  to  a  representation  of  epidemics  of  typhus 
fever.  Thus,  we  read  of  a  highly  contagious  fever  setting  in  sud- 
denly, attended  with  constipation,  with  a  rapid,  feeble  pulse,  with 
dizziness  and  delirium,  with  injected  eyes,  with  a  dry  tongue,  with 


794  MEDICAL    DIAGNOSIS. 

noises  in  the  ears  and  deafness,  with  starting  of  the  tendons,  with 
watchfulness  or  stupor,  and  with  red  patches  and  purple  spots 
scattered  over  the  surface  of  the  body.  The  features  which  the 
plague  does  not  share  with  typhus  are  nausea  and  vomiting,  pale 
face,  an  alarmed,  despairing  look  of  the  countenance,  haemoptysis, 
and,  above  all,  the  buboes  and  carbuncles  in  different  parts  of  the 
body,  and  the  clearing  mind  when  they  happen.  Moreover,  the 
disease  is  of  much  shorter  duration.  Death  generally  takes  place 
between  the  third  and  the  fifth  day,  or  convalescence  sets  in  on 
the  sixth  or  the  seventh  day,  or  early  in  the  second  week.  It 
may,  however,  be  protracted  by  the  long-continuing  suppuration 
of  the  buboes. 

The  relations  of  typhus  fever  to  cerebro-spinal  fever  will  be 
best  discussed  with  the  latter  disease. 

Cerebro-spinal  Fever.  —  This  disease  is  also  known  as 
apoplectic  cerebral  typhus,  as  cerebro-spinal  typhus,  as  epidemic 
meningitis,  and  as  epidemic  cerebro-spinal  meningitis,  and  is  the 
affection  which  has  been  called  in  this  country  spotted  fever.  It 
was  formerly  very  prevalent  in  portions  of  the  United  States,  as 
we  judge  by  the  descriptions  of  Hale,  Gallup,  North,  and  Ames; 
but  the  present  generation  of  physicians  had  little  knowledge  of 
it  until  about  simultaneously  with  the  severe  epidemic  in  Germany 
in  1863  and  1864  it  invaded  this  country  and  committed  great 
ravages,  especially  in  some  of  the  New  England  States,  in  New 
York,  and  in  Pennsylvania.  Since  that  time  it  has  become  natu- 
ralized here,  as  Ziemssen  states  to  be  also  the  case  in  Germany.* 

Cerebro-spinal  meningitis  does  not  always  present  exactly  the 
same  symptoms.  These  vary  somewhat  according  to  the  struc- 
tures which  bear  the  brunt  of  the  disease.  Usually,  however, 
marked  cerebro-spinal  phenomena  preponderate ;  in  some  instances 
the  evidences  of  pulmonary  embarrassment  or  of  blood-deteriora- 
tion are  very  prominent.  Again,  the  signs  of  spinal  disturbance 
may  prevail  over  those  of  the  cerebral,  or  the  reverse. 

The  disease  may  be  gradual  in  its  approach,  feelings  of  chil- 
liness, succeeded  by  headache,  by  tenderness  at  the  nape  of  the 
neck,  by  nausea,  and  by  pain  in  the  back  and  joints,  preceding  its 
full  development.     Generally  its  onset  is  sudden;  a  violent  chill 

*  Cyclopaedia  of  Practice  of  Medicine,  vol.  ii.,  1875. 


FEVERS.  795 

is  quickly  followed  by  intense  headache,  vomiting,  and  extreme 
prostration.  However  the  beginning,  the  disease  usually  soon 
reaches  its  full  development.  The  excruciating  headache  is  as- 
sociated with  vertigo,  and  often  with  delirium  and  stupor.  The 
headache  may  remit,  but  does  not  cease  during  the  attack.  An- 
other symptom  of  the  fully-developed  disease  is  stiffness  of  the 
deep  muscles  of  the  neck,  so  that  the  patient  cannot  bend  the  head 
forward;  and  the  stiffness  may  pass  into  marked  contraction,  and 
the  head  be  thrown  backward  and  rigidly  fixed.  The  contraction 
of  the  muscles  may  extend  along  the  spine,  which  frequently  is 
painful,  not  specially  to  the  touch,  but  on  movement  of  any  kind; 
sometimes,  moreover,  severe  spontaneous  pain  occurs.  There  are 
also  pain  at  the  nape  of  the  neck,  and  in  the  loins  and  shooting 
to  the  lower  extremities,  and  pain  at  the  epigastrium,  and  a  feel- 
ing of  contraction  of  the  chest.  The  face  has  a  fixed  or  suf- 
fering expression  ;  the  patient  is  extremely  restless;  he  trembles; 
talks  incoherently;  when  spoken  to,  does  not  appear  to  hear;  his 
pupils  are  generally  dilated,  and  there  may  be  dimness  of  sight, 
or  double  vision.  The  skin  is  dry,  generally  very  sensitive,  or  in 
some  parts  the  sensibility  is  increased,  in  others  diminished,  and 
the  cutaneous  surface  is  frequently  spotted  with  a  red  eruption, 
erythematous  and  roseolous, — an  eruption  which  often  becomes 
brownish,  and  then  for  the  most  part  rapidly  petechial,  and  wholly 
uninfluenced  by  pressure ;  or  the  purple  spots  may  be  seen  from 
the  start.  Vesicles,  too,  are  apt  to  appear  on  the  lips.  They 
show  themselves  from  the  third  to  the  sixth  clay  of  the  disease, 
while  the  eruption  is  seen  on  the  first  day,  or  may  at  all  events  be 
detected  by  the  third  day.  The  pulse  at  first  is  either  natural  or 
slow;  but  it  becomes  rather  frequent  and  irregular,  and  commonly 
remains  accelerated  throughout  the  disease,  showing  extraordinary 
variations  in  a  few  hours.  The  tongue  is  moist  or  dry,  and  brown; 
the  breathing  often  hurried  and  shallow  ;  and  the  urine  I  have 
often  noticed  to  contain  large  quantities  of  urates  and  to  be  slightly 
albuminous.  The  bowels  are  at  the  outset  constipated,  but  as  the 
malady  advances  they  become  relaxed.  There  is  usually  persist- 
ent irritability  of  the  stomach,  with  great  thirst,  and  spasmodic 
contractions  or  convulsive  movements  in  the  muscles  of  the  ex- 
tremities. With  these  symptoms,  to  which  those  of  exhaustion 
become  plainly  added,  the  disorder  progresses  to  its  close,  present- 


796  MEDICAL,    DIAGNOSIS. 

ing  now  and  then  strange  and  delusive  remissions,  soon  followed 
by  distinct  exacerbations.  In  fortunate  instances  the  morbid 
phenomena  gradually  lose  their  violence,  and  the  patient,  greatly 
emaciated,  enters  upon  a  tedious  convalescence. 

But  though  these  are  the  symptoms  which  frequently  recur  in 
epidemics,  yet,  as  already  indicated,  they  cannot  always  be  taken 
as  the  standard  expression  of  the  disease.  Most  of  them  were 
observed  in  the  formidable  examples  of  the  malady  which  have 
but  recently  been  encountered  in  this  country;  and  they  have  also 
been  met  with  in  the  epidemic  cerebro-spinal  meningitis  prevalent 
in  Germany.  As  regards  one  of  these  epidemics,  we  are  told  by 
a  distinguished  observer*  that  the  spleen,  early  in  the  affection, 
enlarges,  but  does  not  continue  tumefied ;  and  that  the  tempera- 
ture reaches  106°  to  108°  Fahr.,  or  even  higher,  without  there 
being  a  proportionate  rise  in  the  pulse;  or  this  may  become  fre- 
quent without  a  corresponding  increase  in  the  temperature,  which, 
moreover,  is  not  sustained  at  the  same  height.  And,  whether  the 
pulse  be  rapid  or  slow,  the  force  of  the  heart's  impulse  is  at  times 
found  to  be  singularly  augmented.  The  irregularity  of  the  tem- 
perature has  also  been  noticed  by  Ziemssen,f  who  states  that  the 
high  temperatures  are  often  interrupted  by  long-continued  normal 
temperatures. 

The  duration  of  the  malady  is  very  various.  Patients  may 
become  rapidly  comatose,  and  die  within  twelve  hours,  before  any 
distinctly  febrile  action  has  begun;  or  may  sink  in  a  few  days; 
or,  on  the  other  hand,  the  complaint  may  pursue  a  very  chronic 
course,  lasting  for  weeks,  and  during  this  time  deafness  and  blind- 
ness, convulsions,  retention  of  urine,  and  partial  palsies — though 
these  are  unusual — may  be  prominent  phenomena.  In  any  case, 
the  prognosis  is  unfavorable;  especially  so  when  the  symptoms 
from  the  onset  are  violent,  or  when  the  signs  of  spinal  disturbance 
preponderate. 

Of  the  cause  of  the  formidable  disease  we  know  little.  It  is 
not  a  malarial  disease ;  for,  though  occasionally  there  is  a  singu- 
lar intermission  or  remission  in  the  symptoms,  there  is  no  regu- 


*  Wunderlich,  Archiv  der  Heilkunde,  No.  III.,  18G5,  quoted  in  Amer. 
Journ.  of  Med.  Sci.  for  Oct.  I860, 
f  Op.  cit. 


FEVEKS.  797 

larity  in  this  respect.  The  temperature-record,  even  of  these 
apparently  malarial  cases,  is  different,  being  irregular;  and  the 
affection  is  unyielding  to  quinine.  Many  look  upon  it  as  modi- 
fied typhus  ;  and  certainly  the  disorder  occurs  epidemically  under 
much  the  same  circumstances  as  typhus,  and  is  a  general  disease, 
not  merely  an  inflammation.  But,  though  kindred  to  typhus,  a 
fever  of  typhous  type,  it  is  due  to  a  different  poison,  and  differs 
broadly  from  typhus  in  being  far  less  contagious,  if  indeed  it  can 
be  regarded  as  contagious  at  all,  and  by  the  inflammatory  lesions 
found  in  the  brain  and  spinal  cord.  To  the  diagnostic  differences 
we  shall  presently  refer. 

Cerebro-spinal  meningitis  attacks  children  very  frequently.  It 
is  more  common  in  winter  and  in  spring  than  in  summer;  though 
I  have  seen  it  in  summer.  It  is  an  affection  very  familiar  to 
military  surgeons ;  it  seizes  on  recruits  who  have  been  subjected  to 
unaccustomed  fatigue  or  have  been  huddled  together  in  unhealthy 
barracks  or  camps.  Attention  to  cleanliness,  good  food,  pure  air, 
sufficient  clothing,  and,  as  far  as  possible,  not  overmarching  raw 
troops,  are  then' its  surest  prophylactics. 

To  determine  the  diagnosis  is  ordinarily  not  difficult :  the  sud- 
den onset  of  the  malady  and  its  epidemic  character  are  safeguards 
against  error.  The  protracted  cases  simulate  typhoid  fever.  They 
resemble  it  in  its  long  duration,  in  several  of  the  cerebral  symp- 
toms, and  in  the  occurrence  of  an  eruption,  and  sometimes  of 
diarrhoea.  They  differ  from  it  in  the  more  abrupt  invasion,  or 
rather  in  the  short  time  in  which  the  disease  reaches  an  alarming 
aspect ;  and  in  the  early  stages  the  violent  headache,  the  constipa- 
tion, the  constant  vomiting,  the  slow  or  normal  pulse,  and  the  cool 
or  but  slightly  heated  skin,  are  unlike  the  signs  of  enteric  fever. 
In  those  cases  in  which  an  eruption  appears,  it  is  noticed,  at  latest, 
by  the  third  or  fourth  day,  not  at  the  end  of  a  week,  as  in  typhoid 
fever;  nor  is  the  rash,  save  in  extremely  rare  instances,  rose- 
colored.  Later  in  the  malady  the  traits  of  distinction  become 
broader  and  broader.  The  prominence  of  the  abdominal  symp- 
toms in  the  one  disorder;  the  continued  violent  headache,  the 
fixed  spinal  pain,  the  hyperesthesia,  the  facial  herpes,  the  severe 
twitchings  or  the  tetanic  rigidity  of  the  muscles,  and  the  absence 
of  marked  enlargement  of  the  spleen,  in  the  other, — are  signs 
the  import  of  which  is  not  easily  overlooked. 


798  MEDICAL    DIAGNOSIS. 

The  suddenness  with  which  the  morbid  phenomena  occasionally 
develop  themselves,  and  the  lulls  that  take  place  in  the  course  of 
the  affection,  may  cause  it  to  be  mistaken  for  the  cerebral  variety 
of  congestive  fever.  But  the  remissions  are  not  so  marked  as  in 
this  pernicious  malady,  nor  are  the  exacerbations  preceded  by  a 
long,  violent  chill.  Moreover,  the  temperature-record  is  differ- 
ent, and  congestive  fever  does  not  begin  with  congestive  symp- 
toms, but  the  first  attack  is  like  that  of  an  ordinary  intermittent 
or  remittent :  hence  we  have  the  history  of  the  case  to  instruct  us. 

From  tetanus  cerebro- spinal  meningitis  may  be  distinguished 
by  its  epidemic  prevalence,  and  by  the  signs  of  mental  disturbance, 
which  are  very  slight  or  wholly  wanting  in  the  former  disorder. 
Generally,  too,  the  sudden  and  painful  spasms,  aggravating  the 
tetanoid  contractions,  and  the  cognizance  of  the  exciting  cause 
of  the  tetanic  convulsions,  such  as  their  following  wounds  or  punc- 
tures, aid  in  interpreting  their  meaning. 

How  can  we  discriminate  between  inflammation  of  the  meninges 
of  the  cord  and  epidemic  cerebro-spinal  meningitis?  Thus:  in 
pure  spinal  meningitis,  as  in  myelitis,  mental  symptoms  are  ab- 
sent; their  presence  in  cerebro-spinal  fever  constitutes  one  of  the 
marked  features  of  the  disease.  The  history  of  the  case  in  the 
former  malady  points  to  cold  and  exposure  or  to  syphilis.  Clonic 
spasms  of  the  extremities  are  more  common;  persisteut  rigidity  of 
the  muscles  is  a  less  striking  peculiarity.  We  find  no  eruption. 
The  paralysis  aids  us  only  if  there  be  coexisting  myelitis  ;  for 
in  pure  cases  of  both  acute  spinal  meningitis  and  of  epidemic 
cerebro-spinal  fever  it  is  a  rare  sequel ;  in  the  latter  affection 
when  it  happens  it  is  generally  limited  in  extent,  the  local  palsies 
being  usually  in  the  course  of  the  cranial  nerves  which  are  envel- 
oped by  the  exudation. 

Tubercular  meningitis  is  distinguished  by  the  much  more  in- 
sidious beginning,  the  much  more  protracted  course,  the  absence 
of  eruption,  and  usually  of  marked  stiffness  of  the  neck,  the  varia- 
tions in  the  pulse  according  to  the  stage  of  the  disease,  the  irreg- 
ular breathing,  and  the  history  of  a  scrofulous  or  tubercular  taint. 

Sporadic  cerebrospinal  meningitis  is  a  rare  disease.  It  runs  a 
much  slower  course  than  the  epidemic  malady,  and  its  spinal 
symptoms  are  less  marked.  In  some  instances  no  retraction  of 
the  head,  or  stiffness  of  the  spine,  or  pain  in  the  extremities,  and 


FEVERS.  799 

but  slight  impairment  of  the  special  senses,  have  been  noticed. 
Perhaps  the  singular  variations  in  temperature  will  be  found  to 
be  absent  in  the  sporadic  malady. 

There  are  other  diseases  with  which  cerebro-spinal  meningitis 
has  been  confounded;  for  instance,  owing  to  the  eruption  and 
to  the  sore  throat  which  may  attend  it,  with  scarlatina.  But  the 
onset  and  the  neck-symptoms  are  very  different;  and  so  is  the 
eruption;  certainly  it  is  different  in  its  course.  Still,  as  regards 
the  onset,  we  must  bear  in  mind  that  both  may  be  ushered  in 
by  convulsions.  An  extremely  rapid  pulse  would  be  in  favor  of 
scarlatina.  Cerebro-spinal  fever  also  resembles  at  times  the  onset 
of  malignant  measles,  but  the  catarrhal  symptoms  and  presently 
the  eruption  guide  us. 

I  have  known  more  than  once  the  disease,  on  account  of  the 
congestion  of  the  lungs  or  the  broncho-pneumonia  which  may 
accompany  it — and  in  some  epidemics  the  lung-affection  is  very 
marked — to  be  mistaken  for  pneumonia.  In  truth,  the  diagnosis 
is  sometimes  far  from  easy.  The  mental  symptoms,  the  intense 
headache,  the  variations  in  the  pulse,  the  hyperesthesia,  the 
vomiting,  the  stiffness  and  retraction  of  the  muscles  of  the  neck, 
the  eruption,  are  distinguishing  traits  of  value ;  but  when  these 
important  symptoms  are  ill  denned,  much  doubt  may  exist.  So 
there  may  if  epidemic  cerebro-spinal  meningitis  become  inter- 
current, as  it  sometimes  does  in  pneumonia  as  well  as  in  other 
acute  affections.  Supervention  of  the  severe  headache,  and  ap- 
pearance of  rigidity  of  the  neck,  of  great  restlessness,  of  hyper- 
esthesia, and  of  coma,  are  the  symptoms  of  most  importance. 

In  some  instances  of  cerebro-spinal  fever  there  is  great  pain, 
with  some  swelling  of  the  joints,  and  the  disorder  is  thought 
to  be  acute  rheumatism.  But  the  head-symptoms,  the  state  of  the 
muscles  of  the  neck,  and  the  dissimilar  course  of  the  malady  soon 
clear  up  the  diagnosis. 

The  poison  may  produce  so  light  a  case  that  the  stiffness  of  the 
neck  may  be  mistaken  for  rheumatism  of  the  cervical  muscles. 
There  is,  however,  even  in  these  instances,  an  unusual  amount 
of  headache,  and  in  a  case  in  which  I  was  consulted  it  became  a 
permanent  condition  for  several  years,  and  then  yielded. 

Urazmia  with  contracted  kidneys  may  give  us  most  of  the  same 
symptoms  as  cerebro-spinal  fever,  especially  headache,  vomiting, 


800  MEDICAL    DIAGNOSIS. 

and  retraction  of  the  head ;  careful  examination  of  the  urine  alone 
will  explain  the  case. 

Lastly,  let  us  look  at  the  clinical  features  separating  cerebro- 
spinal fever  from  the  disease  it  is  most  like, — typhus  ;  let  us  con- 
trast its  phenomena  with  those  of  this  affection,  which  in  many- 
respects  it  so  closely  resembles.  Both  diseases  are  apt  to  prevail 
at  the  same  time  ;  both  attack  all  classes  and  ages ;  both  are  evi- 
dently attended  with  dissolution  of  the  blood, — but  this  alteration 
in  the  blood  occurs  much  more  rapidly  and  is  much  more  marked 
in  epidemic  cerebro-spinal  fever  than  in  ordinary  cases  of  typhus;* 
the  eruption  is  different  from  that  of  the  common  form  of  tvphus; 
there  is  less  delirium  ;  a  less  intense  fever  ;  the  affection  is  gener- 
ally of  much  shorter  duration  ;  the  countenance  is  not  of  a  dusky 
hue  and  stupid,  but  pale  or  of  a  sallow  color,  and  dull  or  express- 
ive of  suffering;  there  is  the  stiffness  of  the  muscles  of  the  neck, 
with  the  fixed  spinal  pain,  and  muscular  contractions  and  other 
signs  of  spinal  or  cerebro-spinal  lesion ;  and  the  herpetic  eruption 
on  the  face.  And,  certainly,  whether  or  not  cerebro-spinal  fever 
be  a  peculiar  form  of  typhus,  clinically  its  manifestations  are 
very  dissimilar  to  those  of  the  usual  varieties  of  this  complaint. 
But  they  are  not  so  dissimilar  to  those  occurring  in  some  epi- 
demics of  malignant  cerebral  typhus,  f 

*  The  deterioration  of  the  Wood  occurs,  indeed,  very  soon  in  spotted  fever. 
In  an  autopsy  of  a  child  that  died  in  twenty-four  hours,  I  found  the  blood 
diffluent  and  black;  in  an  adult  patient  who  had  been  sick  but  two  days, 
I  detected  blowing  sounds  in  the  heart,  evidently  of  blood-origin.  The 
poisoned  blood  unquestionably  gives  rise  to  many  of  the  nervous  symptoms, 
and  it  is  on  the  blood  and  the  nervous  centres  that  the  poison  mainly  acts. 

f  An  extraordinary  case,  bearing  on  the  relationship  of  the  complaints 
under  discussion,  was  under  my  charge  in  1865  at  the  Pennsylvania  Hospital. 
See  Case  XII.  of  a  series  of  typhus  fever  cases,  published  in  Amer.  Journ.  of 
Med.  Sci.,  Jan.  1866. 

For  accounts  of  the  late  epidemics  in  this  country,  consult  the  observations 
of  Uphain,  in  the  Boston  Med.  and  Surg.  Journ.,  vol.  lxviii.,  1863 ;  the  com- 
munications of  Gerhard,  Jewell,  and  others,  in  the  Transactions  of  the  Phila. 
College  of  Physicians,  Amer.  Journ.  of  Med.  Sci.,  1864  and  1865;  the  Publi- 
cations of  the  Massachusetts  Medical  Society,  vol.  ii.  ;  also  Stille's  monograph 
on  Epidemic  Meningitis;  Githens,  Amer.  Journ.  of  Med.  Sci.,  July,  1867; 
various  papers,  by  Liddell  and  others,  published  in  the  same  journal ;  Knapp, 
New  York  Medical  Becord,  Aug.  1872;  Lewis  Smith,  Amer.  Journ.  of  Med. 
Sci.,  Oct.  1873  ;  Baker,  Report  of  State  Board  of  Health  of  Michigan,  1875; 
Upham,  Fifth  Annual  Keport  of  State  Board  of  Health  of  Massachusetts, 


FEVEES.  801 

Cerebrospinal  fever  may,  during  an  epidemic,  complicate  other 
acute  maladies,  and  mix  its  symptoms  curiously  with  them.  With 
the  attack  the  difficulty  does  not  pass  off,  for  it  may  leave  all 
kinds  of  want  of  power  and  local  palsies,  besides  derangement  of 
vision,  permanent  deafness,  impaired  intelligence,  epilepsy,  per- 
sistent headache,  chronic  meningitis,  which  may  be  indeed  the 
cause  of  the  headache,  and  chronic  hydrocephalus.  In  one  in- 
stance I  have  known  an  extraordinary  swelling  of  the  whole  body 
to  follow ;  the  skin  is  hard,  tense,  and  greatly  thickened,  pits  very 
little  on  pressure,  except  around  the  ankles,  and  is  tightly  drawn 
over  the  face;  this  swelling  and  thickening,  very  much  like  a 
general  sclerema,  has  now  lasted  for  upward  of  eleven  years,  and 
has  been  attended  with  a  feeling  of  numbness  in  the  skin  and  a 
moderate  amount  of  anaemia.  There  is  no  palsy  or  albuminuria ; 
the  patient  suffers  little  inconvenience,  except  from  her  size.  She 
has  a  waxy  countenance,  and  looks  like  a  very  fat  woman. 

Relapsing  Fever. — This  is  a  form  of  fever  characterized  by 
its  rapid  course  and  its  proneness  to  relapse.  Epidemics  of  this 
disease — and  it  occurs  only  in  epidemics — are  frequently  encoun- 
tered in  Ireland  and  in  Scotland.  In  this  country  it  was,  until 
lately,  almost  unknown. 

The  disorder  is  decidedly  acute.  Its  invasion  is  sudden,  and 
marked  by  rigors,  pain  in  the  back  and  limbs,  vertigo,  severe 
headache,  and  nausea  and  vomiting.  Fever  is  soon  developed, 
and  rises  high ;  there  are  severe  muscular  pains,  particularly  in 
the  muscles  of  the  extremities;  the  pulse  is  very  rapid  ;  the  tem- 
poral arteries  throb ;  the  tongue  is  covered  with  a  thick  white 
fur.  The  bowels  are,  as  a  rule,  constipated.  In  many  cases  there 
is  engorgement  of  the  liver,  with  yellowness  of  skin ;  and  in  nearly 


1874,  and  Boston  Med.  and  Surg.  Journ.,  Sept.  1874;  and  Joseph  Jones, 
Memoirs,  vol.  i. 

To  contrast  our  epidemics  with  those  in  Great  Britain  and  on  the  Continent, 
see  discussions  and  papers  by  Murchison,  Sanderson,  and  others,  in  Medical 
Times  and  Gazette,  Lancet,  and  Medical  Press  and  Circular,  of  the  past  fifteen 
years;  and  Beports  in  Brit,  and  For.  Med.-Chir.  Bev.,  Oct.  1868,  and  in 
Dubl.  Quart.  Journ.,  Aug.  1868  ;  Gordon,  ib.,  May,  1867  ;  Ziemssen  and  Heis, 
in  Archiv  fur  Klin.  Med.,  Bd.  i.  ;  Klebs,  Virchow's  Archiv,  1865;  Hirsch, 
Die  Meningitis  Cerebro-Spinal.  Epidemie,  Berlin,  1866,  and  Trans.  Epidem. 
Soc,  vol.  ii.  ;  Ziemssen,  Cyclopaedia  of  Practice  of  Medicine,  vol.  ii.,  1875; 
Prey,  Wien.  Med.  Presse,  No.  22,  1879. 

51 


802  MEDICAL    DIAGNOSIS. 

all  there  are  epigastric  tenderness  and  marked  enlargement  of  the 
spleen.  The  matter  ejected  from  the  stomach  is  greenish,  or  some- 
times black  and  like  coffee-grounds.  Minute  points  of  extra va- 
sated  blood  are  not  uncommonly  seen  upon  the  integument.  The 
urine  is  scanty,  and  contains  usually  bile-pigment,  some  albumen, 
and  hyaline  casts.  On  the  fifth  or  the  seventh  day,  though  some- 
times not  until  the  tenth,  the  symptoms  subside  as  speedily  as  they 
set  in,  a  profuse  perspiration  preceding  their  decided  abatement, 
and  the  temperature  falls  to  the  norm  or  even  below.  Convales- 
cence is  now  apt  to  be  rapid,  and  seemingly  complete,  the  patient 
being  up  and  going  about;  but  the  apparent  return  to  health  does 
not  last  long.  Ordinarily  after  a  week,  therefore  on  the  twelfth 
or  fourteenth  day  from  the  first  beginning, — sometimes  sooner, 
rarely  later, — the  attack,  preceded  perhaps  by  a  slight  rise  in  tem- 
perature for  an  evening  or  two,  returns,  presenting  again  the  same 
signs,  and  again  terminating  by  a  critical  sweat  in  convalescence. 
This  second  attack  may  be  short  and  mild ;  but  it  may  be  both 
longer  and  of  graver  character  than  the  first.  It  is,  at  times,  fol- 
lowed by  another,  and  yet  another,  relapse.  When  the  patient 
finally  throws  off  the  disease,  he  is  very  weak,  and  his  blood  is 
much  impoverished.  He  shows  a  tendency  to  dropsy  of  the  ex- 
tremities ;  and  blowing  murmurs,  evidently  not  organic,  are  per- 
ceptible while  listening  to  the  heart.  These  murmurs,  however, 
may  also  be  heard  during  the  paroxysms.  Is  the  patient  really 
well  during  the  intermission  ?  He  appears  so ;  yet  his  spleen  re- 
mains enlarged,  the  pulse  is  apt  to  be  slow,  the  action  of  the  heart 
weak,  and  the  arthritic  pains  do  not  entirely  disappear. 

Relapsing  fever  has  an  intimate  connection  with  destitution. 
It  is  a  contagious  but  far  from  a  fatal  disorder,  except,  perhaps, 
in  the  negro.  In  fatal  cases  death  sometimes  happens  during  the 
first  paroxysm  as  the  result  of  syncope,  of  hemorrhage  into  the 
brain  or  from  the  lungs ;  or  it  may  occur  suddenly  during  the  in- 
termission, from  paralysis  of  the  heart.  But  the  most  common  ter- 
mination of  the  cases  having  an  unfavorable  issue  is  in  consequence 
of  states  which  have  been  induced  by  the  malady,  such  as  lobu- 
lar inflammation  of  the  lung,  abscess  of  the  spleen  or  the  kidney 
leading  to  pysemia,  chronic  diarrhoea,  dropsy,  parotitis,  palsies.  At 
times  the  patient  perishes  in  a  condition  similar  to  the  collapse  of 
cholera,  though  the  collapse  is  more  protracted  and  the  pulse  can 


FEVERS.  803 

be  felt,  and  discharges  from  the  bowels  are  by  no  means  a  constant 
accompaniment.  The  extreme  prostration,  attended  with  great 
coldness  of  the  skin,  may  last  for  days.  It  is  more  particularly 
met  with  in  the  "bilious"  or  "bilious  typhoid"  form  of  the 
malady, — a  dangerous  variety,  in  which  severe  vomiting,  jaundice, 
and  delirium  are  encountered,  and  the  paroxysm  is  not  followed  by 
a  distinct  intermission  or  remission,  but  often  by  the  signs  of  col- 
lapse alluded  to,  in  which  ursemic  symptoms  have  been  more 
particularly  noticed.*  The  collapse,  however,  may  happen  not 
only  at  the  close  of  the  paroxysm,  but  in  the  remission,  whether 
this  be  distinct  or  not,  or  in  a  subsequent  paroxysm ;  and  this 
may  be  the  case  no  matter  what  variety  of  the  disorder  we  have 
to  deal  with,  and  whether  or  not  the  grave  symptoms  be  due  to 
ursemia. 

Yet  it  will  probably  be  found  that  the  state  of  the  kidneys  and 
of  the  urinary  secretion  has  commonly  a  great  deal  to  do  with  the 
graver  phenomena  of  the  malady.  Acute  renal  disease  with  albu- 
men and  tube-casts  in  the  urine  was  discerned  by  Obermeierf  in 
two-thirds  of  his  cases;  and  as  regards  the  urine,  EiesenfeldJ 
found  that  the  urea  during  the  first  paroxysm  was  always  increased, 
and  that  this  increase  continued  beyond  the  crisis.  The  products 
of  the  heightened  tissue-metamorphosis  may  be  retained,  and  thus 
grave  symptoms  arise. 

There  is  no  constant  lesion  in  relapsing  fever,  unless  it  be  the 
lesion  in  the  spleen.  This  organ  is  greatly  enlarged,  and  presents 
numerous  round  or  irregularly-shaped  bodies,  of  white  or  yellow- 
ish-white color.§  Myriads  of  minute  organisms,  spirilla,  have 
been  discovered  in  the  blood  just  prior  to  the  outbreak  of  the 
paroxysm,  and  at  its  height. 

The  description  of  the  malady  has  been  chiefly  taken  from  the 
epidemics  which  have  been  commented  on  by  Jenner,  Lyons,  and 
Murchison.  But  we  have  had  relapsing  fever  both  in  Xew  York 
and  in  Philadelphia ;  and  I  have  encountered  the  disorder.  Its 
features  have  appeared  to  me  much  the  same  as  in  the  epidemics 


*  Hermann,  Account  of  St.  Petersburg  Epidemic,  Schmidt's  Jahrb.,  No.  6, 
1865.     See  also  further  observations  in  Meissner's  article,  ib.,  No.  2,  1870. 
f  Virchow's  Arcbiv.  1869,  Bd.  slvii. 
1  lb.  Pastau,  ib. 


804  MEDICAL    DIAGNOSIS. 

already  described ;  and  this  is  also  the  case  •with  the  fever  as  met 
with  in  New  York.* 

The  diagnosis  of  the  malady  cannot  be  made  positively  during 
the  primary  seizure.  Yet  the  presence  of  the  fever,  while  an 
epidemic  prevails,  may  be  suspected  from  the  sudden  fierce  be- 
ginning of  the  attack ;  from  the  fact  of  the  high  fever-heat  of  10-4° 
to  107°  showing  itself  in  less  than  twenty-four  hours,  and  ex- 
hibiting either  a  morning  remission  of  one  to  two  degrees  and  the 
maximum  of  temperature  in  the  early  afternoon  or  evening,  or 
but  little  difference  between  morning  and  evening,  until  the  rapid 
and  great  fall  which  takes  place  at  the  crisis;  and  from  the  char- 
acter of  the  gastric  symptoms.  Relapsing  fever  resembles  yellow 
fever  in  its  short  duration  and  in  some  of  its  manifestations.  But 
there  is  this  evident  difference  :  in  yellow  fever  the  paroxysm  or 
febrile  stage  is  usually  much  shorter ;  the  symptoms  in  the  re- 
mission do  not  subside  nearly  so  completely ;  this  stage  is  a  very 
brief  one  as  compared  with  the  decided  intermission  of  relapsing 
fever;  the  black  vomit  of  yellow  fever  does  not  come  on  until 
the  stage  of  collapse  is  reached ;  and  this  far  more  fatal  malady 
presents  lesions  in  the  liver  and  heart  which  are  not  found  in 
relapsing  fever,  while  it  does  not  show  the  extraordinary  en- 
largement of  the  spleen. 

From  typhoid  and  typhus  fevers,  relapsing  fever  may  be  dis- 
tinguished by  the  shorter  prodromata,  by  the  presence  of  jaundice, 
by  the  absence  of  the  characteristic  eruptions,  and  by  the  short 
period  during  which  the  symptoms  last.  Again,  critical  sweats 
with  the  rapid  cessation  of  the  fever  are  not  likely  to  be  seen  in 
these  disorders,  certainly  not  in  typhoid  fever;  and  the  intense 
continuous  febrile  heat,  as  indicated  by  the  thermometer,  the  se- 
vere muscular  and  arthritic  pains,  the  tenderness  over  the  liver 
and  the  spleen,  and  in  some  cases  the  early  collapse  without  ap- 
parent cause,  are  characteristic ;  while,  on  the  other  hand,  delirium 
and  stupor  are  rarely  encountered  in  relapsing  fever.  After  the 
relapse  has  taken  place,  the  diagnosis  is  easy,  if  the  case  have 
been  watched  during  the  first  attack.  But,  should  it  not  have 
been  under  notice  before,  it  may  be  at  times  difficult,  if  not  wholly 
impossible,  to  say  whether  we  are  dealing  with  relapsing  fever  or 

*  Alonzo  Clark,  Medical  Eecord,  March,  1870. 


FEVERS.  805 

with  a  relapse  of  typhoid  or  typhus  fever.  And  this  difficulty  is 
enhanced  by  the  want  of  uniformity  of  the  symptoms  in  the  second 
onset  of  the  strangely  recurring  malady,  and  the  close  similarity 
they  occasionally  show  to  those  of  typhoid  or  of  typhus  fever. 
Another  difficulty,  too,  is  presented  by  the  fact  that  relapsing  fever 
may  exhaust  itself  in  the  first  paroxysm.  But  this  is  a  very  un- 
usual occurrence,  and  the  abortive  cases  are  generally  light. 

In  looking  at  the  different  forms  of  continued  fever  which  have 
just  been  passed  in  review,  we  cannot  help  being  struck  with  the 
many  features  which  they  possess  in  common.  They  are  nearly 
all  apt  to  occur  as  epidemics  or  endemics.  They  are  nearly 
all  more  prevalent  in  densely-populated  parts  of  the  country,  or 
among  masses  of  men,  than  in  localities  where  the  population  is 
scattered.  They  all  exhibit  a  strong  disposition  to  run  a  certain 
well-defined  course  before  terminating.  In  truth,  it  is  doubtful 
whether  any  medical  means  can  cut  short  this  course ;  for  a  spe- 
cific treatment  for  any  of  the  forms  of  continued  fever,  by  which 
they  may  be  controlled  with  the  same  readiness  as  the  malarial 
fever,  has  not  yet  been  discovered.  Yet  in  the  low  forms  of  fever 
we  gain  much  by  interposing  to  prevent  the  disease  from  under- 
mining, step  by  step,  the  vital  powers.  The  greatest  peril  in 
these  fevers  is  generally  from  exhaustion.  Usually,  if  that  can 
be  guarded  against,  the  malady  is  nearly  conquered.  To  use  the 
forcible  words  of  Stokes,*  "  In  a  disease  which  is  under  the  con- 
trol of  the  mysterious  law  of  periodicity,  every  hour  of  com- 
pelled life  is  a  clear  gain." 

Periodical  Fevers. 

These  fevers  are  characterized  by  the  distinct  periodicity  of 
their  phenomena:  they  exhibit  intervals  during  which  the  patient 
is  wholly  or  nearly  free  from  febrile  disturbance.  With  the  ex- 
ception of  one  (and  its  place  here  is,  indeed,  doubtful),  they  are 
all  owing  to  that  poison,  so  prolific  of  disease,  termed  marsh 
miasm  or  malaria.  This  noxious  agent  gives  rise  to  a  group  of 
fevers,  ever  betraying  their  common  origin  by  their  strong  family 
resemblance  :  alike  in  occurring  in  low,  swampy  localities ;  alike  in 

*  Clinical  Lectures  on  Fevers,  Medical  Times  and  Gazette,  1854. 


806  MEDICAL    DIAGNOSIS. 

most  of  their  symptoms,  and  in  the  difficulty  of  eradication  from 
the  system;  alike  in  the  secondary  lesions,  in  the  enlargement  of 
the  spleen  and  of  the  liver,  and  in  the  altered  condition  of  the 
blood,  which  they  leave  behind  them ;  and  also  alike  in  being 
under  the  control,  absolute  and  immediate,  of  cinchona  in  its 
various  preparations.  Along  with  the  forms  of  miasmatic  fever, 
I  shall  describe  yellow  fever;  not  because  I  believe  it  to  be  of 
identical  nature,  but  on  account  of  the  similarity  of  the  prominent 
symptoms. 

The  paroxysm  of  the  fever  conies  on  with  a  chill  :  the  face 
becomes  pale,  the  lips  bluish ;  the  teeth  chatter ;  the  skin  is  cold 
to  the  touch ;  there  is  a  feeling  of  uneasiness  and  fatigue.  After 
a  period  varying  commonly  from  half  an  hour  to  an  hour,  this 
cold  stage  passes  off.  Now  we  find  decided  heat  of  the  surface, 
with  restlessness,  thirst,  a  full,  rapid  pulse,  muscular  pains,  a 
scanty  secretion  of  urine ;  in  other  words,  active  febrile  symptoms. 
These  continue  for  hours,  for  a  period  always  much  longer  than 
the  first  stage :  then  a  sweat  breaks  out  all  over  the  body ;  the 
pulse  becomes  softer  and  less  frequent;  the  secretions  are  fully 
re-established ;  and  this  sweating  stage  terminates  the  paroxysm. 

The  patient  is  now,  for  the  time  being,  well;  but  the  disease 
soon  recurs :  in  from  twenty-four  to  seventy  hours  the  paroxysm 
repeats  itself.  In  the  former  case  we  call  the  fever  a  quotidian  ; 
in  the  latter,  a  quartan.  The  tertian  type  is  before  us  when  the 
paroxysm  sets  in  again  in  about  forty-eight  hours;  the  double 
tertian,  when  we  find  a  daily  attack,  but  those  of  alternate  days 
alone  corresponding  in  time  and  severity.  The  period  between 
the  ending  of  one  attack  and  the  beginning  of  another  is  spoken 
of  as  the  intermission,  or  apyrexia ;  while  the  time  between  the 
beginning  of  the  two  paroxysms,  including  the  first  with  its  suc- 
ceeding intermission,  is  called  the  interval. 

The  varied  types  of  the  fever  present  marked  differences  in  the 
character  and  duration  of  the  several  stages.  The  tertian  has 
generally  the  longest  hot  stage,  the  quartan  the  longest  cold  stage. 
In  the  quotidian  there  is  a  short  cold  stage,  followed  by  a  hot 
stage  which  may  last  for  upward  of  fifteen  hours.  Occasionally 
the  stages  are  very  irregular  and  anomalous.  Thus,  the  sweating 
stage  may  precede  the  cold  stage,  or  it  may  be  the  only  one  which 
shows  itself;    or,  again,  the  rigor  may  be  altogether  wanting. 


FEVERS.  807 

Sometimes  there  are  no  distinct  stages;  but  the  patient  has  a 
"  dumb  ague,"  which  manifests  itself  at  definite  periods  by  a  feel- 
ing of  great  depression,  or  of  a  severe  pain  at  some  portion  of 
the  body,  or  by  chilly  sensations,  or  by  headache,  or  by  nausea  and 
vomiting,  or,  as  I  have  seen,  by  excruciating  pain  over  the  kidneys, 
and  almost  entire  suppression  of  urine;  or  by  spasmodic  obstruc- 
tion of  the  intestine.* 

Now,  cases  of  this  kind  are  difficult  to  distinguish  from  organic 
disease.  We  can  do  so  only  by  laying  stress  on  their  strictly 
periodical  nature ;  by  noting  that  the  curious  manifestations  cease 
entirely  to  recur  with  intensity.  This  does  not  happen  where  the 
symptoms  are  not  caused  by  a  lurking  malarial  poison;  for  idio- 
pathic disorders  exhibit  the  phenomena  of  structural  change  or  of 
deranged  function  at  all  times, — not  merely  on  certain  days  or  at 
certain  hours.  It  is  true  that  among  the  inhabitants  of  miasmatic 
districts  some  complaints,  and  particularly  those  of  the  nervous 
system,  display  a  well-defined  periodicity ;  but  here,  too,  are  found 
the  significant  traits  of  organic  or  functional  disturbance  between 
the  decided  exacerbations  of  the  symptoms. 

Then,  again,  we  must  remember  that  diseases  may  assume  an 
apparently  intermittent  character,  being  worse  every  second  day, 
and  yet  not  be  malarial  at  all.  Even  mania,  as  Schroeder  van 
der  Kolk  tells  us,  may  take  this  type.  The  whole  aspect  of  the 
symptoms,  and  a  tentative  treatment  with  quinine,  will  help  to 
inform  us  as  to  the  true  nature  of  the  malady. 

The  temperature  in  intermittent  fever  shows  a  peculiar  record, 
and  one  which,  in  doubtful  cases,  may  be  turned  to  great  ad- 
vantage. Notwithstanding  the  marked  sense  of  chilliness,  the 
thermometer  rises  suddenly  and  rapidly  to  a  high  degree ;  there 
may  be  a  slight  elevation  of  temperature  for  an  hour  before 
a  chill,  but  the  marked  rise  begins  with  the  chill.  Even  during 
the  decided  chill  of  the  beginning  of  the  paroxysm  it  indicates 
105°  or  more  in  the  axilla.  The  temperature  remains  stationary 
or  continues  to  rise,  though  not  much,  during  the  hot  stage,  and 
during  the  sweating  stage  falls  at  first  slowly,  then  rapidly,  until 
it  comes  down  to  about  the  normal  heat.  During;  the  chill  the 
peripheral  temperature  is  decidedly  lowered ;  during  the  hot  stage 

*  Cases  of  Hoyt,  Atlanta  Med.  and  Surg.  Journ.,  Sept.  1875. 


808  MEDICAL    DIAGNOSIS. 

it  is  increased.  But  with  the  ending  of  the  paroxysm  it  is  found 
that  the  fall  has  been  equally  rapid.  In  the  intermission  the  ther- 
mometer in  the  axilla  marks  a  natural  temperature,  or  one  some- 
what lower  than  in  health.  It  rises  again  quickly  with  each 
paroxysm.     No  other  malady  presents  these  variations. 

The  diagnosis  of  an  ordinary  and  regular  intermittent  is  easy. 
Leaving  the  other  malarial  fevers  out  of  consideration,  only  two 
morbid  states  present  recurring  rigors  and  febrile  excitement,  and 
are,  therefore,  apt  to  be  confounded  with  it:  hectic  fever,  and 
chills  attending  upon  suppuration  in  deep-seated  parts.  Now, 
hectic  fever  differs  in  this  from  an  intermittent :  it  is  simply  a 
fever  of  irritation,  the  cause  of  which  a  careful  scrutiny  will 
generally  detect.  We  find  it  accompanying  many  chronic  diseases 
in  which  destruction  of  tissue  occurs,  especially  phthisis ;  and  the 
chronic  affection  has  its  own  signs,  which  exist  at  all  times,  whether 
the  symptomatic  fever  be  present  or  not.  Then  its  outbreaks  are 
irregular.  Several  often  take  place  within  the  twenty-four  hours ; 
their  intermissions  are  incomplete;  the  temperature  does  not  fall 
as  in  intermittent  fever,  for  there  is  not  complete  defervescence ; 
and  although  the  paroxysms  may  begin  with  chilliness,  they  are 
not  ushered  in  by  a  well-defined  rigor.  Further,  they  are  apt  to 
be  morning  paroxysms,  and  are  not  modified  by  antiperiodics. 
"Whenever,  indeed,  we  find  an  intermitting  fever  not  influenced 
by  these  agents,  it  ought  to  arouse  suspicion,  and  all  the  internal 
organs,  particularly  the  lungs,  should  be  carefully  explored.  Thus 
only  can  serious  errors  in  diagnosis  be  guarded  against. 

AVhen  pus  forms,  and  especially  when  it  forms  in  internal  cavi- 
ties, it  betrays  its  presence  by  rigors,  followed  by  more  or  less 
fever.  But  these,  unlike  the  chills  of  ague,  do  not  repeat  them- 
selves at  definite  periods.  Moreover,  in  the  midst  of  the  apparent 
intermission,  febrile  signs  or  other  manifestations  of  a  seriously 
disordered  system  may  be  discovered.  The  chills  of  ordinary 
pyaemia  are  distinguished  by  the  same  phenomena;  then  the 
rigors,  unlike  the  malarial  malady,  are  often  characterized  by  the 
profuse  sweating  which  immediately  follows  them,  rather  than  by 
an  active  development  of  the  fever. 

Gallstones  which  form  in  the  radicles  of  the  hepatic  duct  in 
the  interior  of  the  liver  may,  as  Frerichs  shows,  give  rise  to  at- 
tacks of  chills  followed  by  heat  and  by  sweating,  easily  mistaken 


FEVEES.  809 

for  ague.  The  fact  that  these  febrile  phenomena  are  preceded 
in  many  instances  of  intra-hepatic  concretion  by  dull  pain  in  the 
hepatic  region,  and  by  sudden  sharp  seizures  of  pain  at  the  lower 
part  of  the  thorax  on  the  right  side,  is  very  significant.  Even 
gallstones  passing  along  the  gall-duct  and  the  common  duct  may 
occasion  febrile  symptoms  like  those  of  an  intermittent,  with  pro- 
fuse hemorrhage,  if  they  have  led  to  inflammation  of  the  passage, 
and  the  paroxysms  may  extend  over  months,  and  then  the  patient 
recover.  Jaundice  is  apt  to  be  a  symptom ;  but  there  is  no  positive 
evidence  of  pysemic  hepatitis.* 

An  affection  which  on  account  of  the  chill  succeeded  by  fever 
might  be  mistaken  for  the  malarial  disorder  is  the  curious  so- 
called  urethral  fever  which  sometimes  arises  after  the  passage 
of  a  bougie,  and  which  may  even  terminate  in  death. f  Our 
knowledge  of  the  introduction  of  the  instrument,  and  the  non- 
recurrence  at  a  fixed  time  of  the  rigor  and  febrile  phenomena, 
furnish  the  points  of  distinction. 

Yet  another  aifection  liable  to  be  mistaken  for  intermittent 
fever  is  syphilitic  fever.  The  fever  may  occur  in  attacks  consist- 
ing of  a  chill,  followed  by  a  hot  stage  and  sweating,  and  be  so 
similar  to  the  malarial  disorder  as  to  lead  to  error.J  The  appar- 
ent ague  fits  happen,  however,  toward  evening,  and  are  succeeded 
or  accompanied  by  severe  headache  and  pains  in  the  bones, — in 
fact,  by  the  same  symptoms  as  the  more  ordinary  form  of  syphi- 
litic fever.  In  the  form  in  which  the  febrile  symptoms  are  con- 
tinuous, these  generally  precede  the  eruption  for  a  week  or  more, 
and  may  continue  after  this  appears. 

In  the  puerperal  state  a  malarial  outbreak  may  happen  which, 
as  Fordyce  Barker§  has  recently  pointed  out,  may  be  mistaken  for 
puerperal  fever.  Unlike  the  latter,  however,  the  puerperal  ma- 
larial fever  is  attended  with  pain  in  the  head,  back,  and  limbs, 
and  does  not  generally  appear  so  soon  after  parturition,  not  there- 
fore between  the  first  and  fifth  days  after  delivery.  Moreover, 
it  has  at  the  beginning  a  great  temperature  rise,  and  marked 

*  Murchison,  Diseases  of  the  Liver. 

f  Eoser,  quoted  in  Brit,  and  For.  Med.-Chir.  Bev.,  Oct.  1867. 
%  See  cases  of  Bassereau,  referred  to  by  Bumstead  in  his  Treatise  on  Vene- 
real Diseases. 

I  Medical  Eecord,  Eeh.  1880. 


810  MEDICAL    DIAGNOSIS. 

remissions  or  intermissions.  Puerperal  malarial  fever  may  lead, 
after  the  twelfth  day,  to  secondary  hemorrhage. 

Remittent  Fever. — This  is  a  fever  pre-eminently  of  hot 
climates  and  malarial  districts.  It  is  the  fever  of  Hungary, 
of  the  Pontine  Marshes,  and  particularly  of  Africa  and  the 
southern  portion  of  the  North  American  continent.  Occasion- 
ally, not  often,  we  meet  with  it  in  winter  and  in  early  spring ; 
very  generally,  during  the  summer  and  autumn  months. 

Remittent  fever  has  no  well-defined  and  constant  prodromic 
symptoms,  except,  perhaps,  a  singular  sense  of  gastric  uneasi- 
ness. It  is  ushered  in  by  a  marked  chill,  soon  succeeded  by 
violent  fever,  which,  after  a  varying  period,  decreases,  and  then 
breaks  out  again.  By  this  time  the  symptoms  of  the  disease  are 
very  apparent.  The  patient  complains  of  pain,  of  fulness  and  of 
throbbing  in  his  head.  He  is  restless  and  distressed ;  his  limbs 
ache;  his  tongue  has  become  coated;  he  suffers  from  thirst,  and 
rejects  the  contents  of  the  stomach.  After  continuing  at  their 
height  from  six  to  eighteen  hours,  these  symptoms  again  subside : 
a  sweat  breaks  out  all  over  the  body;  the  irritability  of  the  stom- 
ach lessens ;  the  patient  is  composed,  even  cheerful ;  his  headache 
has  nearly  ceased,  and  he  falls  into  a  quiet  slumber.  But  this 
lull  is  not  of  long  duration,  not  longer  than  some  hours.  Soon 
the  active  fever  is  rekindled  :  the  skin  is  as  hot  and  dry  as  before, 
the  pulse  as  full,  frequent,  and  hard ;  the  spleen  is  observed  to  be 
swollen ;  and  the  other  symptoms  return  with  increased  intensity, 
again  to  abate,  again  to  recur,  until  either  the  exacerbations  are 
effaced  and  the  fever  assumes  a  continued  type  and  then  gradu- 
ally lessens,  or  else  subsequently  the  remissions  become  better  and 
better  defined, — more,  indeed,  like  intermissions  than  remissions. 
In  the  progress  of  the  disease  at  and  after  its  height  the  pulse  is 
generally  quicker  and  weaker  than  at  first. 

The  temperature  rises  markedly  with  the  first  chill,  and  con- 
tinues to  rise  during  the  high  fever  that  follows.  With  the  sweat- 
ing stage  it  declines  by  several  degrees,  to  rise  to  a  greater  height 
than  previously  with  the  succeeding  febrile  phenomena;  then 
again  there  is  a  fall  in  the  remission,  with  another  quick  rise  in 
the  fever,  which  may  attain  a  very  high  point,  marking  from 
105°  to  108°.  The  greatest  height  is  usually  reached  in  the  ex- 
acerbation of  the  third  dav.     After  this  the  remissions  become 


FEVERS. 


811 


less  distinct,  and  may,  indeed,  be  recognizable  only  by  the  ther- 
mometer ;  the  whole  fever  is  more  like  a  continuous  one.  Sub- 
sequently to  the  ninth  day  usually  the  remissions  are  very  marked, 
the  difference  between  the  heat  in  them  and  the  exacerbations 
being  three  degrees  or  more.  The  exacerbations  become  less  and 
less  high,  and  soon  cease,  the  temperature  falling  perhaps  pre- 
viously to  below  the  norm.  In  cases  in  which  the  fever  remains 
for  a  long  time  continuous,  irregular  remissions  occur,  especially 
toward  the  end,  though  the  fever  may  preserve  its  continuous 
type  more  or  less  to  the  end. 

Fig.  53. 


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Temperature  in  a  case  of  remittent  fever  of  moderate  severity,  ending  in  recovery 
on  the  twelfth  day.    The  chart  shows  also  the  pulse  and  the  respiration. 


The  average  duration  of  the  fever,  unless  protracted  by  com- 
plications, is  from  nine  to  twelve  days.  Its  most  common  type 
is  quotidian,  or  rather,  perhaps,  double  tertian,  the  exacerba- 
tions of  alternate  days  corresponding  in  severity,  in  duration,  and 
even  in  the  nature  of  the  symptoms.     Sometimes  there  are  two 


812  MEDICAL   DIAGNOSIS. 

exacerbations  in  twenty-four  hours, — a  duplicated  quotidian, — or 
the  paroxysms  have  a  tertian  form.  The  exacerbations  may  occur 
anytime  in  the  twenty-four  hours;  in  many  instances  morning 
exacerbation  is  noticed,  and  I  have  met  with  more  cases  in  which 
the  paroxysm  comes  on  in  the  afternoon  than  in  the  evening. 

The  urine  in  remittent  fever  presents  much  the  same  changes, 
though  in  a  different  degree,  as  those  occurring  in  intermittent 
fever.  Its  color  is  much  deeper  and  its  acidity  greater,  but 
during  convalescence  the  urine  passed  rapidly  becomes  alkaline, 
throwing  down  an  abundant  deposit  of  phosphates.  During  the 
active  stages  of  the  fever  there  is  an  increase  of  urea,  not  simply 
above  the  standard  of  health,  but  even  above  that  in  intermittent 
fever;  and  this  increase  of  urea  is  attended  with  a  diminution  of 
uric  acid — unlike  what  happens  during  the  paroxysm  of  ague — 
and  of  the  coloring  and  extractive  matter;  while,  as  convalescence 
sets  in,  the  urea  decreases  in  amount,  and  the  other  ingredients 
mentioned  increase.*  A  copious  deposit  of  urates,  forming  with 
the  phosphates  as  it  were  a  critical  discharge,  is  noticed  as  the  fever 
subsides,  and  is  analogous  to  what  takes  place  after  the  paroxysm 
in  intermittent  fever.  At  no  stage  does  the  urine  contain  albu- 
men, as  it  often  does  in  typhus,  and  so  generally  in  yellow  fever. 

Remittent  fever  is  readily  recognized :  the  rise  and  fall  of  its 
febrile  signs  are  too  striking  to  escape  observation.  Its  charac- 
teristic traits  are  more  closely  allied  to  those  of  intermittent  fever 
than  to  those  of  any  other  disorder.  But  there  are  these  points 
of  contrast:  in  intermittent  fever,  each  paroxysm  begins  with  a 
chill,  which  is  not  the  case  in  remittent  fever;  for  after  the  first 
paroxysm  there  is  rarely  a  marked  chill,  and  even  the  chill 
ushering  in  the  disease  is  usually  not  violent.  After  each  febrile 
exacerbation  comes  an  abatement, — not  an  intermission,  for  the 
thermometer  shows  that  the  fever  does  not  wholly  leave;  the 
tongue  remains  coated,  and  the  gastric  derangement  does  not 
entirely  cease ;  the  patient  is  not  well,  as  after  a  fit  of  ague. 
The  symptoms  grow  and  decline;  they  do  not  appear  and  dis- 
appear. In  both  affections  we  may  have  herpes  labialis  at  the 
decline,  but  it  is  more  common  in  remittent  than  in  intermittent. 


*  Joseph  Jones,   Observations  on   Malarial   Fever.      Extracted  from  the 
Transactions  of  the  American  Medical  Association. 


FEYEES.  813 

Owing  to  the  presence  of  jaundice  in  many  cases  of  bilious 
remittent  fever,  the  disease  is  often  mistaken  for  acute  congestion 
of  the  liver.  Here,  again,  the  exacerbations  and  remissions  serve 
as  distinguishing  marks;  and  so,  too,  in  separating  the  gastric 
complications  of  bilious  remittent  fever  from  acute  gastric  inflam- 
mation. The  severe  headache  is  also  a  distinctive  feature  of  value, 
and  the  herpes  labialis,  which  is  a  not  uncommon  symptom. 

Under  ordinary  circumstances,  there  is  very  little  likelihood  of 
confounding  with  each  other  typhoid  and  remittent  fevers.  The 
lines  between  the  two  diseases  are  too  strongly  drawn :  no  marked 
periodicity  exists  in  typhoid  fever,  and,  on  the  other  hand,  we  find 
no  diarrhoea,  no  eruption,  no  thoracic  symptoms,  no  deafness,  and 
no  very  great  prostration  in  remittent  fever.  But  instances  are  met 
with  in  which  the  diagnosis  is  not  easy,  because  the  symptoms  of 
the  two  maladies  are  blended.  Thus,  in  a  typhoid  fever  occurring 
in  a  malarious  region  there  are  often  distinct  exacerbations  and 
remissions  obscuring  the  real  ailment.  The  malarial  influence 
has  set  its  stamp  on  the  disease,  and  may  for  several  days  com- 
pletely veil  it ;  but  soon  its  real  nature  becomes  manifest.  The 
great  weakness ;  the  low  delirium ;  the  tympanitic  abdomen ;  the 
thin  passages,  so  unlike  the  dark,  hard  stools  of  remittent  fever, 
— all  unfold  the  true  character  of  the  disease.  Sometimes  a  cer- 
tain periodicity  is  witnessed  in  typhoid  fever  as  it  is  approaching 
a  favorable  termination ;  the  afternoon  or  evening  rise  of  temper- 
ature is  most  marked,  the  morning  remission  very  great.  Here  a 
knowledge  of  the  previous  history  of  the  case  guards  against  error. 
We  shall  presently  again  refer  to  the  symptoms  of  periodicity  in 
fevers  of  low  type  in  examining  into  the  so-called  typho-malarial 
fever. 

Further,  not  unfrequently,  after  an  attack  of  remittent  fever 
has  lasted  for  ten  or  twelve  days,  these  symptoms  are  noticed : 
great  muscular  debility,  jerking  of  the  tendons,  picking  at  the 
bedclothes,  dark,  dry  tongue,  and  weak  pulse,  perhaps  diarrhoea. 
The  fever  becomes  of  a  continued  type.  It  is  these  cases  which 
have  given  rise  to  the  opinion  that  bilious  fever  often  changes 
into  typhoid  fever.  But  in  reality  it  is  not  so  much  the  specific 
typhoid  fever,  with  its  enteric  lesions,  as  a  typhoid  condition,  that 
is  developed. 

During  the  exacerbations  of  remittent  fever  the  cerebral  symp- 


814  MEDICAL,    DIAGNOSIS. 

toms  are  sometimes  almost  identical  with  those  of  idiopathic  in- 
flammation of  the  brain.  There  is  severe  headache,  with  violent 
beating  of  the  arteries  of  the  neck  and  face,  a  wild  eye,  intoler- 
ance of  light,  and  even  delirium.  Were  the  patient  now  seen  for 
the  first  time,  he  would  be  at  once  pronounced  to  be  laboring 
under  acute  meningitis,  and  probably  be  bled  and  freely  purged, 
— a  treatment  which,  fortunately,  is  of  advantage  to  him.  Sud- 
denly the  pulse  loses  its  throbbing  character,  a  perspiration  covers 
the  surface,  and,  as  if  by  magic,  the  cerebral  disturbance  ceases 
until  the  next  paroxysm  redevelops  it. 

Cases  of  this  kind  are  readily  enough  recognized,  if  we  know 
something  of  their  history.  If  we  are  not  familiar  with  it,  we 
have  to  await  the  remission  for  their  explanation ;  and  after  the 
sudden  withdrawal  of  the  signs  of  disorder  of  the  brain,  it  is 
hardly  possible  to  have  doubts  as  to  the  meaning  of  the  acute 
nervous  symptoms,  should  they  recur.  It  cannot  be  a  meningitis 
we  are  dealing  with, — a  steady,  progressing  disease,  and  one  never 
exhibiting  such  strange  freaks  of  intermission.  But  occasionally 
the  symptoms  show  themselves  under  circumstances  where  a  mala- 
rial poison  is  not  suspected  to  be  at  work. 

A  young  gentleman,  of  studious  habits,  while  diligently  pre- 
paring for  a  college  examination,  was  seized  with  violent  headache 
and  fever.  The  sense  of  fulness  in  the  head  was  unbearable,  the 
fever  was  high,  there  was  nausea  with  great  gastric  irritability. 
These  symptoms  lasted  for  nearly  twenty-four  hours,  and  then 
subsided  in  the  forenoon,  to  become  aggravated  in  the  evening. 
Delirium  followed  by  great  drowsiness  was  perceived  at  an  early 
hour  of  the  third  day  of  the  disease.  The  case  now  assumed  a 
very  alarming  aspect.  Local  blood-letting  was  resorted  to  with 
some  relief,  and  in  a  few  hours  the  symptoms  were,  fortunately, 
favorably  modified  :  the  headache  was  much  less,  the  mind  was 
again  quite  clear.  Although  the  patient  had  never  suffered  from 
a  malarial  fever,  he  had  spent  part  of  his  summer  vacation  in  the 
marshy  neighborhood  of  "Washington ;  but  several  months  had 
elapsed,  and  winter  was  setting  in.  The  time  of  the  year,  there- 
fore, and  his  immediate  occupations,  rather  favored  the  view  of 
an  inflammation  of  the  brain.  But  the  evident  remission  in  the 
cerebral  symptoms,  the  coated  state  of  the  tongue,  and  that  in- 
describable malarial  look  of  the  countenance,  which  became  daily 


FEVERS.  815 

more  apparent,  decided  me  upon  administering  quinine.  The 
evening  exacerbation  came,  but  was  far  less  severe.  The  nature 
of  the  case  wag  now  evident :  the  quinine  treatment  was  vigor- 
ously pursued,  and  the  patient  soon  recovered. 

The  violent  headache  and  delirium  were  in  this  case  observed 
to  be  in  connection  with  well-defined  febrile  signs.  Occasionally 
one  or  both  of  the  symptoms  mentioned  last  during  the  remission, 
while  the  fever  abates.  I  have  even  met  with  them  occurring;  in 
paroxysms  without  fever  being  present,  as  in  the  following  case 
seen  a  number  of  years  ago  : 

A  young  lady  of  delicate  constitution  was  attacked,  in  Septem- 
ber, with  remittent  fever.  The  disease  ran  its  course  without  any 
unusual  symptoms ;  a  violent  headache,  but  little  if  any  wander- 
ing of  the  mind,  being  observed  during  the  daily  exacerbations. 
After  the  tenth  day,  the  fever  lessened,  and  the  disease  assumed  a 
continued  type ;  but  very  soon  afterward,  every  evening  for  three 
days,  between  five  and  six  o'clock,  a  boisterous  delirium  set  in, 
lasting  for  three  or  four  hours,  and  once  nearly  all  night.  It  was 
followed  by  a  profound  sleep,  from  which  she  woke  up  with  a 
clear  mind.  Strange  to  say,  during  these  fits  the  pulse  was  not 
accelerated,  and  there  was  no  heat  of  skin.  The  third  attack  was 
not  so  very  severe,  as  the  patient  was  already  in  part  under  the 
influence  of  decided  doses  of  quinine ;  the  fourth  was,  I  am  sure, 
prevented  by  this  drug. 

In  both  these  cases  the  symptoms  approached  those  of  the  con- 
gestive type  of  the  disease,  and  the  issue  appeared  at  one  time 
doubtful.  Generally  speaking,  remittent  fever,  unless  it  be  of  the 
congestive  variety,  has  a  favorable  prognosis.  It  is  difficult  for 
us,  living  in  a  century  in  which  the  remarkable  effects  of  bark 
are  so  well  understood,  to  believe  that  the  complaint  was  once  so 
fatal,  and  that  so  many  deaths  should  have  taken  place  from  a 
disorder  over  which  we  now  exercise  so  undoubted  a  control.  But 
the  long  list  of  distinguished  names  that  have  fallen  victims  to 
it,  among  them  Cromwell,  James  I.,  and  the  Emperor  Charles 
"V.,*  proves  the  medical  skill  of  former  times  to  have  been  in- 

*  Prom  the  record  of  the  Emperor's  sickness,  as  given  by  the  historian 
Mignet  (Charles  V  au  Monastere  de  Yuste),  we  may  learn,  what  fortunately 
now  we  hardly  have  an  opportunity  of  observing,  the  features  of  remittent 
fever  when  left  to  itself. 


816  MEDICAL    DIAGNOSIS. 

sufficient  for  its  cure.  In  our  day,  the  consequences  of  remittent 
fever  are  more  to  be  dreaded  than  the  disease  itself.  We  often 
find,  as  its  sequela?,  obstinate  intermittens,  enlargement  of  the 
liver  and  spleen,  dropsy,  protracted  anaemia,  headache,  and  im- 
paired activity  of  mind. 

It  is  in  this  malarial  cachexia  that,  on  pricking  the  finger 
and  examining  a  drop  of  the  blood  thus  obtained,  we  are  apt 
to  detect  a  large  number  of  those  particles  and  masses  of  black 
or  dark  color  and  irregular  shape  to  which  Frerichs  has  partic- 
ularly called  attention.      2sot  that  the  pigment-matter  is  found 

Fig.  54. 


A  drop  of  ljlood  takon  from  the  finger  of  a  man  the  subject  of  malarial 
cachexia.  The  granules  of  pigment,  as  well  as  the  larger  fragments  of 
irregular  form,  are  seen  among  the  blood-globules.  The  pigment  was 
for  the  most  part  black ;  some  of  the  particles  were  recklbh  browu. 

merely  in  the  cachexia  following  remittent  fever.  We  observe  it 
in  the  blood  in  the  severer  forms  of  any  malarial  disease ;  and  it 
is  very  probable  that  the  spleen  is  the  principal  seat  of  its  forma- 
tion, and  that  it  is  chiefly  derived  from  a  destruction  of  the  red 
globules.  The  pigment  is  in  great  part  carried  from  the  spleen 
to  the  liver,  where  it  remains ;  or  it  passes  through  this  viscus  to 
the  lungs,  brain,  and  kidneys.  The  clogging  of  the  coarser  frag- 
ments in  the  capillaries  of  the  liver  may,  as  Frerichs  suggests, 
by  interference  with  the  portal  circulation,  explain  the  intestinal 
hemorrhage  and  diarrhoea  which  attend  some  severe  cases  of 
remittent  fever;  while  the  cerebral  phenomena,  or  albuminuria, 
hseinaturia,  or  suppression  of  urine  may  also  be  caused  by  reten- 


FEVERS.  817 

tion  of  pigment,  in  the  one  case  in  the  capillaries  of  the  brain,  in 
the  other  in  those  of  the  Malpighian  bodies.  Thus,  then,  would 
be  solved  some  of  the  anomalous  symptoms  of  malarial  fevers. 
But  the  abundance  of  pigment  does  not  occur  in  all;  and  whether 
a  peculiar  quality  or  an  unusual  intensity  of  the  miasm  produces 
it,  is  undetermined.  In  a  diagnostic  point  of  view,  though  from 
the  very  evident  grayish  or  ash-colored  hue  of  the  skin,  and  the 
singular  character  of  the  symptoms,  we  may  suspect  that  we  have 
to  deal  with  the  pathological  state  under  discussion,  we  cannot 
be  sure  of  it  until  we  have  examined  the  blood  microscopically. 
And  here,  too,  it  seems  to  me  that  the  question  of  the  amount  of 
pigmentary  matter  present  must  not  be  overlooked.  For  pigment 
may  be  found  in  the  blood  of  those  who  never,  to  their  knowledge, 
have  had  intermittent  fever,  and  who  certainly  present  no  signs 
of  malarial  poisoning.* 

To  the  peculiar  appearance  of  the  tongue  which  those  under 
the  malarial  influence  may  show,  Osborn  has  directed  particular 
attention. f  There  is  a  distinct  lateral  boundary  of  the  organ,  an 
appearance  of  indentation  transversely,  and  the  inferior  surface 
appears  to  have  encroached  upon  the  superior  and  lateral  borders. 

Since  the  discovery  by  Bence  Jones  of  the  existence  in  animal 
textures  of  a  substance  resembling  quinia,  the  diminution  of  this 
"animal  quinoidine"  has  been  thought  to  occur  in  malarial  disease. 
The  interesting  experiments  of  Rhoads  and  Pepper!  favor  this 
view;  though  we  cannot  regard  the  matter  as  settled,  for  it  has 
been  found§  that  the  fluorescent  substance  is  introduced  in  the 
food  taken,  and  is  rapidly  excreted.  The  more  rigid  diet  of  fever 
patients  might  thus  explain  the  apparently  abnormal  decrease  of 
the  animal  quinoidine. 

In  children,  a  fever  of  remittent  type  is  observed,  the  nature 
of  which  has  been  a  subject  of  the  gravest  controversy.  By  some 
it  is  ascribed  to  the  irritation  of  worms ;  by  others  it  is  regarded 
as  only  a  variety  of  the  ordinary  malarial  fever.  Now,  there  can 
be  little  doubt  that  what  is  called  infantile  remittent  is  rarely  a 


*  J.  F.  Meigs,  Pennsylvania  Hospital  Keports,  vol.  i.,  1868. 
f  Transactions  of  the  American  Medical  Association,  vol.  xx. 
J  Pennsylvania  Hospital  Keports,  1868. 
\  Chalvet,  Gazette  Hebdomadaire,  v.,  1868. 

52 


818  MEDICAL    DIAGNOSIS. 

miasmatic  disorder.  It  is  often  a  gastro-enteritis  connected  with 
verminous  irritation  or  produced  by  errors  in  diet;  or  a  typhoid 
fever, — an  affection  which  nowr  and  then  occurs  even  in  very 
young  children.  What  has  given  rise  to  this  confusion  is,  that 
all  febrile  diseases  in  children  exhibit  a  much  greater  periodicity 
than  in  adults,  and  in  all  cerebral  symptoms  are  apt  to  be  present. 
To  distinguish  the  two  maladies  alluded  to  from  true  remittent 
fever,  we  must  study  particularly  their  manner  of  beginning  and 
their  probable  origin,  and  note  the  peculiarities  of  the  abdominal 
symptoms.  Then  we  may  lay  stress  on  the  irregular  mode  and  the 
unequal  duration  of  the  febrile  exacerbations.  Sometimes,  also, 
by  close  scrutiny,  the  characteristic  eruption  of  a  low  continued 
fever  may  be  found  in  an  apparent  remittent. 

But  some  of  these  cases  of  remittent  fever  are  really  of  malarial 
origin  ;  even  in  very  young  children  this  may  be  their  source.  I 
saw,  for  instance,  some  years  ago,  a  little  girl,  three  years  of  age, 
who  had  a  distinctly  malarial  remittent  fever,  which  was  checked 
by  antiperiodics.  During  the  violent  exacerbations  she  was  very 
delirious ;  her  face  had  a  most  anxious,  frightened  look ;  her 
screams  could  be  heard  all  over  the  house.  In  the  remissions 
she  was  perfectly  sensible,  but  there  wras  gastric  irritability,  and 
the  bowels  were  very  constipated. 

Congestive  Fever. — This  is  a  malignant,  destructive,  ma- 
larial fever,  which  may  be  either  of  the  intermittent  or  of  the 
remittent  form.  The  pernicious  attacks  are  of  the  tertian  or  of 
the  quotidian  type.  While  they  are  at  their  height,  there  is  in- 
tense congestion  of  one  or  several  internal  organs,  and  with  the 
abnormal  condition  of  the  circulation  a  dangerous  perversion  of 
the  function  of  innervation  is  associated.  From  this  state  the 
patient  may  rally,  but  only  to  fall  a  victim  to  another  paroxysm 
unless  art  intervene  to  shield  him  from  his  doom. 

The  symptoms  of  this  violent  malady  vary  according  to  the 
organ  more  specially  disturbed,  and  to  the  extent  of  the  derange- 
ment of  the  nervous  system.  We  have,  thus,  several  distinct 
varieties,  of  which  I  shall  describe  the  most  prominent. 

The  gastro-enteric  form  is  common  in  our  Southwestern  States. 
Its  distinctive  features  are  nausea  and  vomiting,  purging  of  thin 
discharges  mixed  with  blood,  intense  thirst,  and  an  equally  intense 
desire  for  air.     There  is  little  abdominal  pain  or  tenderness,  but 


FEVERS.  819 

a  weak,  frequent  pulse  and  very  great  restlessness.  The  patient 
complains  of  a  sense  of  sinking  and  of  weight,  and  of  burning 
heat  in  the  stomach.  His  breathing  is  deep-drawn  ;  to  each  expi- 
ration succeed  two  short  inspirations.  The  face,  hands,  and  feet 
are  pale  and  cold  ;  the  features  shrunken.  Sometimes  these  symp- 
toms continue  for  several  days,  and  gradually  increase  in  intensity, 
in  spite  of  nature  making  efforts  at  reaction.  More  frequently 
reaction  does  take  place;  the  skin  becomes  hot,  the  pulse  feeble, 
and  the  stormy  symptoms  subside  or  wholly  yield,  until  another 
outbreak,  which  is  very  apt  to  be  deadly,  occurs.  The  usual 
length  of  the  fatal  paroxysm  is  stated  by  Parry,*  in  his  short  but 
interesting  sketch  of  the  disease,  to  be  from  three  to  six  hours. 

The  thoracic  variety  of  the  malady  is  often  combined  with  the 
one  just  described.  Its  most  characteristic  trait  is  violent  dyspnoea, 
caused  by  overwhelming  congestion  of  the  lungs.  It  is,  perhaps, 
the  most  rapidly  destructive  of  all  the  forms  of  the  disastrous 
affection. 

In  the  cerebral  variety  there  is  intense  congestion  of  the  brain ; 
and  sometimes  effusion  of  serum  into  the  ventricles  takes  place, 
or  even  rupture  of  the  blood-vessels.  The  abnormal  state  of  the 
brain  manifests  itself  either  by  coma  or  by  delirium.  In  the 
former  case,  there  is  usually  preceding  stupor  with  occasional 
delirium ;  the  pulse  is  slow  and  full ;  the  face  is  dull,  and  either 
flushed  or  livid;  indeed,  some  of  the  symptoms  which  are  ob- 
served in  apoplexy  show  themselves.  When,  on  the  other  hand, 
delirium  is  marked,  we  have  much  the  same  morbid  phenomena 
as  in  acute  meningitis :  the  patient  is  wild ;  he  sings,  he  cries. 
He  may  die  in  this  state  without  coma  supervening ;  but  a  coma- 
tose condition  generally  succeeds  rapidly  to  the  fierce  excitement. 
Should  recovery  take  place,  the  delirium  gradually  ceases. 

Another  variety  much  dwelt  upon  is  the  so-called  algid  form. 
This  is  not  often  seen  in  this  country ;  Maillotf  noticed  it  in  Cor- 
sica and  Algeria.  The  disease  is  more  than  a  mere  continuation 
of  the  cold  stage  of  a  paroxysm :  commonly  the  characteristic 
symptoms  manifest  themselves  during  the  period  of  reaction. 
The  pulse  slackens,  and  finally  ceases ;  the  extremities,  face,  and 


*  American  Journal  of  the  Medical  Sciences,  July,  1843. 
f  Traite  des  Fievres  intermittentes,  Paris,  1836. 


820  MEDICAL    DIAGNOSIS. 

trunk  become  in  succession  rapidly  cold.  There  is  no  thirst;  the 
skin  feels  like  marble;  the  breath  is  cold;  the  voice  broken. 
The  mind  is  clear;  the  expression  of  the  countenance  impassive, 
and  like  that  of  a  dead  man.  There  may  be  vomiting  and  chole- 
raic discharges.  These  symptoms  go  on  steadily  toward  death, 
unless  decided  reaction  be  brought  about. 

Now,  in  none  of  these  forms  of  congestive  fever  is  the  first 
paroxysm  apt  to  be  of  a  pernicious  character.  In  the  majority  of 
instances  the  disease  begins  as  ordinary  periodic  fever,  and  it  is 
only  in  the  second  or  third  paroxysm  that  the  alarming  symptoms 
appear.  Nor  is  the  first  congestive  paroxysm  likely  to  prove 
mortal ;  generally  it  is  not  until  the  second  or  third  that  a  fatal 
issue  is  to  be  apprehended.  But  this  is  no  excuse  for  neglecting 
to  provide  for  the  patient's  safety  by  the  promptest  treatment. 
Indeed,  whenever  we  are  dealing  with  a  periodical  fever  in  dis- 
tricts where  intermittents  or  remittents  are  known  to  assume  a 
malignant  form,  we  must  be  constantly  on  the  lookout  for  the 
possibility  of  their  becoming  of  the  pernicious  type.  Proper 
watchfulness  will  sometimes  detect,  even  at  the  onset  of  the 
attack,  by  the  unusual  prolongation  of  the  cold  stage,  or  by  the 
irregularity  of  the  pulse,  by  the  great  sensitiveness  in  the  splenic 
region  and  by  the  pain  which  pressure  there  may  occasion  all  over 
the  body,  or  by  an  imperfect  hot  stage,  or  by  the  feeling  of  internal 
heat  while  the  surface  is  really  cold,  the  danger  that  is  approach- 
ing, and  arrest  its  further  steps  by  the  bold  use  of  antiperiodics.* 

The  cause  of  this  desperate  disease  is  evidently  a  highly  active 
malarial  poison;  and  once  in  the  system,  it  remains  for  a  long 
time.  Thus,  should  the  patient  even  weather  the  first  attack 
completely,  he  is  not  wholly  out  of  danger;  for  he  has  not  en- 
tirely got  rid  of  the  morbid  influence.  He  may  have  a  second 
seizure  quite  as  dangerous  within  the  same  season. 

Hemorrhagic  Malarial  Fever. — Closely  connected  with  congest- 

*  For  observations  illustrative  of  the  different  forms  of  the  disorder,  see 
Louis,  New  Orleans  Journal,  vol.  iv.  ;  Ames,  ibid. ;  Holmes,  American  Med- 
ical Intelligencer,  vol.  xxxix. ;  Ford,  Southern  Medical  Journal,  vol.  iv. 
Also  Bartlett  on  the  Fevers  of  the  United  States;  Dickson,  Elements  of 
Medicine;  Semenas,  De  la  Fievre  pernicieuse  chez  lez  Enfants,  Paris,  1848; 
Henoch,  Berlin.  Klinische  Wochenschrift,  1873;  Sullivan,  Medical  Times 
and  Gazette,  March,  1876. 


FEVERS.  821 

ive  fever,  indeed  in  a  certain  sense  a  form  of  it,  is  that  per- 
nicious malady  which  is  attracting  in  this  country  more  and  more 
attention,  and  is  known  as  the  yellow  disease,  icterode  pernicious 
fever,  malarial  hsematuria,  or  hemorrhagic  malarial  fever.  It 
is  the  same  disease  as  that  which  some  of  the  French  writers 
have  long  described  as  hsematuric  bilious  fever,  and  is  found  in 
intensely  malarial  places,  sometimes  in  epidemics.  It  usually 
occurs  in  those  who  have  already  suffered  much  from  malarial 
fevers,  and  is  almost  always  ushered  in  by  a  marked  chill,  longer 
usually  and  more  intense  than  the  patient  has  had  in  the  pre- 
ceding seizure  of  intermittent, — for  often  the  dangerous  paroxysm 
is  preceded  by  one  of  ordinary  kind.  Soon  after  the  protracted 
chill,  distressing  nausea  and  vomiting  are  noticed,  as  well  as 
headache,  great  restlessness,  and  rapidly  developed  deep  jaundice. 
The  fever  which  follows  the  chill  is  not  high,  the  pulse  is  rarely 
extremely  rapid,  the  patient  is  very  thirsty.  In  a  few  hours  after 
the  chill,  pain  in  the  right  hypochondrium,  in  the  epigastrium, 
and  over  the  kidneys  is  encountered,  and  a  dark-colored,  bloody 
urine  is  voided.  Sometimes  hemorrhages  occur  also  from  the 
nose  and  bowels.  The  type  of  the  fever  is  either  intermittent  or 
remittent ;  occasionally  it  is  continuous.  The  bloody  urine — for  I 
believe  the  dark-colored  urine,  judging  from  the  specimens  I  have 
examined,  to  be  bloody — is  at  times  associated  with  considerable 
albumen  and  with  tube-casts. 

If  the  case  progress  unfavorably,  the  pulse  rises,  cold  sweats 
occur,  purpuric  spots  appear  on  the  skin,  and  the  signs  of  uraemic 
poisoning  are  not  unusual.  In  the  intermission  or  remission  the 
symptoms  abate  considerably,  jaundice  and  bloody  urine  cease  to 
a  great  extent,  perhaps  almost  entirely ;  at  least  this  is  true  of 
the  latter  symptom ;  but  they  recur  in  the  paroxysms,  which  may 
happen  every  day  or  every  ten  or  twelve  hours. 

The  disease  may  prove  fatal  in  three  days ;  but  generally  it  lasts 
longer.  Convalescence  is  apt  to  set  in  slowly,  and  not  until  the 
urine  has  entirely  and  permanently  cleared.  The  liver  and  spleen 
may  remain  for  a  time  greatly  enlarged. 

As  regards  the  diagnosis  of  the  disease,  there  are  but  two 
diseases  that  closely  resemble  it.  One  is  intermittent  hcematuria. 
Now,  undoubtedly  some  of  the  cases  of  this  which  have  been  de- 
scribed were  cases  of  the  malady  under  discussion ;  but  in  those 


822  MEDICAL.    DIAGNOSIS. 

to  which  the  name  can  be  fairly  given  the  absence  of  marked 
malarial  elements,  of  fever  and  of  jaundice,  supplies  the  distin- 
guishing trait.  From  yellow  fever,  for  which  hemorrhagic  mala- 
rial fever  may  be  readily  mistaken,  it  differs  in  the  speedy  occur- 
rence of  marked  jaundice,  in  the  bloody  urine,  in  the  extreme 
rarity  of  black  vomit,  in  the  course  of  the  fever  with  its  recurring 
paroxysms,  and  in  the  high  degree  of  malarial  poisoning  which 
the  history  of  the  case  proves.* 

Before  proceeding  to  the  discussion  of  another  subject,  I  shall 
here  devote  a  few  pages  to  the  consideration  of  some  of  the  ir- 
regular forms  and  modifications  of  malarial  poisoning,  and  to 
its  share  in  producing  febrile  disorders  of  blurred  and  uncertain 
type.  Practically,  this  is  of  great  importance,  and  specially  of 
importance  to  American  physicians. 

In  the  first  place,  I  shall  speak  of  the  chronic  malarial  poison- 
ing so  often  seen  among  inhabitants  of  malarial  districts.  It 
manifests  itself  by  lassitude,  debility,  torpor  of  the  liver,  and 
enlargement  of  the  spleen.  The  stools  are  often  black,  the  diges- 
tion is  impaired,  the  complexion  sallow.  Occasionally  attacks  of 
jaundice  occur,  which  rather  relieve  than  aggravate  the  unhealthy 
state  of  the  system.  Sometimes  the  noxious  influence  shows  itself 
in  another  way  :  the  patient  is  seized  with  nausea,  and  with  gastric 
irritability  so  great  that  almost  everything  he  takes  is  instantly 
rejected.  The  tongue  is  coated,  the  skin  dryish;  but  he  has  little 
if  any  fever.  The  bowels  are  confined,  the  urine  is  turbid.  He 
is  restless,  and  as  weak  as  if  he  had  typhoid  fever ;  but  he  has 
neither  an  eruption  nor  diarrhoea.  His  sleep  is  disturbed,  and  he 
often  suffers  with  hyperesthesia  of  the  scalp,  and  neuralgic  pain 
shooting  over  the  forehead  and  causing  twitching  of  the  eyelids. 
After  remaining  from  six  to  seven  days  in  this  condition,  his 
nails,  perhaps  at  a  certain  hour  every  day,  are  noticed  to  become 
bluish;  or  he  feels  chilly,  and  a  slight  fever  immediately  after- 
ward sets  in.     The  return  of  these  febrile  symptoms  is  checked 

*  The  literature  of  the  subject  is  becoming  extensive.  Among  the  most 
valuable  publications  are  those  of  R.  F.  Michel,  New  Orleans  Journal  of 
Medicine,  July,  1869;  Osborn,  ib.,  Jan.  1869;  Norcom,  Address  before  the 
Medical  Society  of  North  Carolina;  E.  D.  McDaniel,  Trans.  Med.  Assoc,  of 
Alabama  ;  E.  D.  Webb,  Hemorrhagic  Malarial  Fever,  Livingston,  Ala. ;  and 
Berenger-Feraud,  Fievre  bilieuse  melanurique,  Paris,  1874. 


FEVEES.  823 

by  quinine,  and  the  patient  enters  upon  a  slow  convalescence, 
remaining  for  a  long  time  enfeebled. 

Cases  of  this  stamp  were,  during  the  late  civil  war,  frequently- 
noticed  among  those  who  had  been  poisoned  by  malaria  in  the 
Southwestern  States  or  in  the  vicinity  of  Washington,  and  who 
had  returned  from  the  army  to  their  homes  in  the  condition  set 
forth.  The  poison  was  often  obscure  in  its  manifestations ;  at 
times  it  became  the  occasion,  remote  if  not  immediate,  of  a  state 
resembling  typhoid  fever,  although  by  no  means  identical  with  it. 

Typho-malarial  Fever. — Fevers  of  hybrid  character,  for  the 
most  part  of  similar  origin,  and  in  some  respects  of  kindred  nature 
to  those  low  states  of  malaria  just  described,  have  long  been  recog- 
nized by  practitioners  in  this  country.  But  it  is  only  since  our 
civil  war  that,  owing  to  the  publications  of  Woodward,  they 
have  been  set  apart  in  a  separate  class.  Now,  one  of  the  most 
marked  forms  of  "  typho-malarial  fever,"  to  adopt  this,  from  a 
practical  point  of  view,  convenient  name,  was  that  curious  fever 
which  so  many  soldiers  brought  with  them  from  the  swamps  of  the 
Chickahominy.  Without  attempting  to  describe  it  in  full,  I  shall 
give  a  sketch  of  the  phenomena  I  noticed  among  those  who  had 
been  with  the  army  during  the  Peninsular  campaign  and  were 
sent  to  Philadelphia  for  medical  treatment. 

The  fever  generally  began  with  a  decided  chill,  to  which  febrile 
excitement  soon  succeeded.  This  chill  was  sometimes,  but  not 
always,  repeated.  Many  cases  of  the  disorder  showed  at  first 
distinct  remissions ;  but  if  the  fever  lasted  for  more  than  a  week 
it  became  continued.  Diarrhoea  was  a  prominent  symptom  from 
the  first;  sometimes  it  preceded  the  disease  by  several  weeks. 
In  the  cases  that  I  saw  in  Philadelphia,  nausea,  vomiting  of  bile, 
and  great  thirst  were  often  present;  the  stools  were  very  frequent 
and  offensive ;  the  eye  was  injected.  There  was  generally  mental 
confusion,  and  not  unusually  wild  delirium ;  but  no  eruption, 
— certainly  no  rose-colored  spots.  The  tongue  was  sometimes 
coated,  but  often  smooth,  clean,  and  moist.  The  debility,  after 
the  affection  had  reached  the  middle  or  the  end  of  the  second 
week,  was  extreme.  The  face  was  pale,  dull  in  its  expression, 
and  became  from  day  to  day,  like  the  rest  of  the  body,  more  and 
more,  emaciated.  It  was  mostly  of  a  very  sallow  hue,  seldom 
really  jaundiced;  at  least  the  conjunctivae,  although  injected,  were 


824  MEDICAL    DIAGNOSIS. 

not  discolored.  The  skin  was  dry,  and  not  very  hot.  The  heart- 
sounds  were  feeble,  as  was  also  the  pulse.  The  lungs  generally 
remained  healthy.  In  the  third  week  of  the  disease  the  patient 
was  apt  to  enter  upon  convalescence,  or  he  died  utterly  exhausted, 
the  freest  stimulation  exerting  but  little  effect. 

The  post-mortem  examinations  were  only  to  a  certain  extent 
satisfactory,  as  regards  the  light  they  threw  upon  the  symptoms. 
In  a  large  number  of  instances,  perhaps  in  the  majority,  neither 
the  solitary  nor  Peyer's  glands  were  ulcerated.  They  were  fre- 
quently, however,  found  to  be  swollen,  and  sometimes  of  very 
dark  color.  The  mucous  membrane  of  the  lower  portion  of  the 
ileum  and  of  the  colon  was  often  seen  to  be  congested,  even  in- 
flamed. The  heart  was  several  times  noted  as  flabby.  None 
of  the  other  organs  presented  any  constant  lesions,  except  that 
the  spleen  was  always  enlarged. 

The  convalescence  from  the  fever  was  slow;  and  during  this 
protracted  recovery  symptoms  occurred  quite  as  striking  as  those 
of  the  fever  proper.  Those  who  got  well  did  so  with  a  broken 
constitution,  and  showed  for  months,  by  their  wan  faces  and  their 
great  debility,  the  hold  the  disease  had  had  upon  them.  Some- 
times, after  gaining  strength  slowly  for  a  time,  they  lost  ground 
again,  and  relapsed  into  a  typhoid  condition  very  similar  to  that 
of  the  first  attack,  except  in  exhibiting  an  almost  undisturbed 
state  of  the  mind  and  a  more  continued  character  of  the  fever. 

The  blood  was  left  much  impoverished.  This  fact  manifested 
itself  by  the  pallid  face,  the  blood-murmurs  heard  over  the  heart, 
or  the  irritability  of  that  organ,  and  the  dark-purple  spots,  un- 
changed by  pressure,  which  showed  themselves  at  times  all  over 
the  body,  and  often  did  not  appear  until  long  after  the  fever  had 
left. 

As  other  sequela?  of  the  fever,  for  in  a  certain  sense  they  were 
sequela?,  I  noticed  milk-leg,  enlargement  of  the  liver,  tympanites, 
parotitis,  and  diarrhoea,  which  ceased  at  times,  but  only  to  break 
out  again.  The  looseness  of  the  bowels  was  not  generally  asso- 
ciated with  ulceration  or  thickening  of  the  intestinal  mucous  mem- 
brane ;  the  solitary  and  agminated  glands  were  prominent,  and 
contained  blackish  pigment.  This  diarrhoea  was  very  obstinate, 
and  was  encountered  long  after  all  other  signs  of  the  C/iickahominy 
fever  had  vanished  from  view. 


FEVERS.  825 

I  have  described  this  fever  because  it  presented  on  a  large  scale 
a  very  striking  illustration  of  the  typho-malarial  disease.  Ac- 
cording to  Woodward,*  the  fever  belonged  to  the  group  which 
was  the  most  frequent  form  of  camp  fever  during  our  late  war. 
It  consisted  of  mixed  cases,  in  which  the  malarial  and  typhoid 
elements  were  variously  combined  with  each  other  and  with  the 
scorbutic  taint,  now  one,  now  the  other  of  these  elements  prepon- 
derating. Prominent  among  the  peculiarities  of  the  malady  were 
a  decided  tendency  to  periodicity,  hepatic  tenderness,  with  an  icte- 
roid  hue  of  the  countenance,  gastric  disturbance,  excessive  enlarge- 
ment of  the  spleen,  a  very  protracted  convalescence,  and  the  ap- 
pearance throughout  of  the  signs  of  a  scorbutic  affection.  The 
rose-colored  rash  and  the  tympanites  of  typhoid  fever  were  generally 
absent.  Diarrhoea  was  ordinarily  very  marked,  and  was  apt  to  be 
persistent.  A  plate  representing  very  artistically  the  intestine  in 
the  so-called  typho-malarial  fever  may  be  found  in  Circular  No.  6, 
War  Department,  Surgeon-General's  Office,  Washington,  1865. 
But  in  a  late  publicationf  Woodward  states  that  in  the  cases  with 
marked  lesion  of  Peyer's  glands  there  was  nothing  in  the  lesion 
to  distinguish  it  from  that  of  ordinary  cases  of  typhoid  fever. 
Very  great  tumefaction  of  the  spleen  and  pigmentary  deposits  in 
various  tissues  and  organs  were  often  encountered.  There  was  a 
group  of  cases  in  which  also  diarrhoea,  with  marked  enlarge- 
ment of  the  spleen  and  congestion  of  the  liver,  had  happened,  in 
which  the  agminated  glands  of  Peyer  were  only  slightly  prominent 
and  the  seat  of  pigment  deposit,  and  in  which  there  was  every 
evidence  of  simple  inflammatory  enlargement  of  the  closed  glands, 
with  patches  of  inflammation  scattered  through  the  intestine. 

Now,  similar  cases  are  seen  by  all  of  us  to  this  day  throughout 
large  portions  of  the  United  States,  and  the  clinical  manifestations 
are  those  of  a  malarial  fever  with  prominent  typhoid  symptoms. 
In  fact,  I  have  already  alluded  to  these  symptoms  when  describing 
remittent  fever,  and  I  will  here  only  add  that  they  may  come  on 
early  in  the  case,  as  well  as  develop  late.  They  are  cases  of 
malarial  fever  complicated  with  a  typhoid  state,  or  more  generally 
lapsing  into  it ;  and,  while  they  present  the  symptoms  of  a  typhoid 


*  Outlines  of  the  Chief  Camp  Diseases. 

f  Transactions  of  International  Medical  Congress,  Philadelphia,  1876. 


826  MEDICAL    DIAGNOSIS. 

condition,  they  are  lacking  in  the  eruption  of  enteric  fever,  and 
in  the  abdominal  phenomena,  if  we  except  diarrhoea  and  some 
abdominal  swelling,  both  of  which  may,  however,  also  be  absent. 
It  is  these  cases,  malarial  primarily,  in  which  the  typhoid  con- 
dition shows  itself,  but  in  which  there  is  not  the  characteristic 
lesion  of  typhoid  fever,  to  which,  in  my  judgment,  the  term  typho- 
malarial  should  be  restricted.  Whether  there  be  also  a  fever  of 
special  type,  produced  by  the  causes  of  the  typhoid  fever  and 
malaria  concurring,  meriting  also  this  name,  is  still  an  open  ques- 
tion, with  the  weight  of  evidence  against  it,  including  Dr.  Wood- 
ward  himself.  True  typhoid  cases  showing  simply  unwonted 
periodicity  and  greater  enlargement  of  the  spleen  from  a  malarial 
complication  should  not,  I  think,  be  included.  They  are  simply 
cases  of  typhoid  fever  with  malaria,  and,  if  we  are  to  give  them 
a  name,  might  be  distinguished  as  "  malario-typhoids." 

Yellow  Fever. — This  formidable  malady  is  known  under 
more  than  one  name.  It  is  the  disease  of  Siam,  the  malignant 
pestilential  fever,  the  Mediterranean  fever,  the  malignant  bilious 
fever  of  America,  the  sailor's  fever,  typhus  icterodes.  It  takes 
its  familiar  appellation  of  yellow  fever  from  the  yellow  tinge 
assumed  during  its  course  by  the  skin,  and  presents  many  valid 
claims  to  be  recognized  as  a  separate  member  of  the  family  of 
fevers. 

Yellow  fever  is  a  distemper  met  with  in  hot  climates  in  low  and 
level  localities  on  the  sea-coast.  It  is  a  virulent  disorder,  propa- 
gated from  the  infected  locality  by  travel  and  commerce  and  by 
substances  containing  the  disease-germs.  Its  source  is  unknown  ; 
and,  though  in  many  respects  like  malaria,  it  is  so  unlike  it  in 
others  that  we  cannot  call  the  complaint  a  malarial  one.  All 
we  know  of  its  cause  is,  that  it  is  due  to  a  specific  poison  which 
does  not  exist  without  a  high  temperature,  and  that  frost  is  its 
greatest  enemy. 

Yellow  fever  is  an  affection  of  short  duration  :  it  rarely  lasts  a 
week  ;  many  die  on  the  third  or  fifth  day  of  the  disease.  It  has 
but  one  paroxysm,  which  is  never  repeated.  This  paroxysm  may 
be  divided  into  three  stages,  which  are  well  marked  in  some 
epidemics,  far  less  so  in  others. 

The  first  stage,  called  that  of  reaction,  is  pre-eminently  the 
febrile  stage.     Its  average  duration  is  from  thirty -six  to  forty- 


FEVERS.  827 

eight  hours.  It  usually  begins  suddenly,  and  is  very  frequently 
ushered  in  by  a  chill.  In  rare  instances  this  is  protracted,  there 
is  great  internal  congestion,  and  death  ensues  before  reaction  oc- 
curs. But  very  much  more  generally  a  short  chill  is  followed  by 
marked  febrile  excitement.  The  skin  is  harsh  and  hot ;  the  pulse 
quick  and  tense,  although  sometimes  it  is  both  easily  compressible 
and  not  very  accelerated.  The  face  is  flushed  ;  the  eye  brilliantly 
injected,  yet  watery.  The  patient  is  conscious,  restless,  anxious, 
and  complains  much  of  the  torturing  pains  in  his  forehead,  loins, 
and  legs ;  and  the  muscles  of  the  extremities  are  sore  when  moved. 
The  breathing  is  hurried  \  the  stomach  irritable,  the  epigastrium 
painful  on  pressure ;  there  is  great  thirst.  The  bowels  are  consti- 
pated ;  the  stools  very  dark-colored.  The  tongue  is  more  or  less 
coated  and  moist;  sometimes  it  is  red,  while  at  other  times  it  re- 
mains natural  throughout  the  disease.  The  febrile  signs  increase 
toward  evening  and  lessen  toward  morning,  but  do  not  distinctly 
remit  until  after  from  thirty-six  to  forty-eight  hours,  when  a  re- 
mission does  occur,  or  when,  to  speak  more  correctly,  the  whole 
aspect  of  the  case  changes. 

The  disorder  now  appears  in  its  second  stage ;  the  fever  sub- 
sides ;  the  pulse  falls  and  becomes  easily  compressible ;  the  head- 
ache is  relieved;  the  breathing  is  no  longer  oppressed.  But  the 
gastric  irritability  does  not  wholly  disappear,  and  a  deep  yellow 
or  orange  hue  gradually  tinges  the  eye  and  the  whole  surface  of 
the  body.  The  patient  is  cheerful,  and  wishes  to  get  out  of  bed. 
And  indeed  his  sufferings  may  be  over,  his  convalescence  may 
have  set  in  :  after  a  few  dark-colored,  biliary  stools,  the  yellow- 
ness of  the  skin  fades,  and  he  slowly  gets  well. 

But  it  is  not  often  that  the  disease  relaxes  its  hold  so  easily : 
more  generally  the  deceptive  improvement  does  not  last  a  day, 
and  after  the  brief  lull  the  struggle  for  life  begins.  The  patient 
grows  again  very  uncomfortable  and  anxious.  In  truth,  the 
symptoms  of  the  first  stage  reappear  with  increased  intensity. 
In  addition,  new  signs,  of  the  gravest  import,  show  themselves ; 
some  of  which  are  clearly  due  to  the  corruption  of  the  blood 
that  the  poison  has  silently  effected.  The  pulse  sinks,  and  be- 
comes slow  and  extremely  irregular  and  compressible ;  the  skin  is 
cool,  dry,  dark,  and  in  some  cases  of  a  bronze  hue,  or  livid,  and 
spots  may  occasionally  be  seen  on  its  surface.     The  stomach  is  as 


830  MEDICAL    DIAGNOSIS. 

Then,  too,  the  red,  suffused  eye  and  the  single  paroxysm  are 
not  witnessed  in  plague.  The  febrile  malady  may  run  on  to  a 
state  of  collapse  as  complete  as  in  Asiatic  cholera;  but,  unlike 
this  destructive  disease,  the  symptoms  of  entire  prostration  are 
preceded  by  fever,  and  not  by  vomiting  or  purging  of  rice-water. 

The  lines  of  demarcation  between  the  ordinary  forms  of  con- 
tinued fever  and  yellow  fever  are  very  broadly  drawn.  It  is 
distinguished  from  relapsing  fever  by  the  different  countenance, 
by  the  supra-orbital  pain,  and,  above  all,  by  the  extreme  rarity  of. 
a  relapse  and  the  infinitely  greater  mortality.  To  typhoid  fever 
it  bears  so  slight  a  resemblance  that  it  is  scarcely  possible  to 
confound  the  two  affections :  one,  a  short,  severe  disease,  with  its 
peculiar  physiognomy  and  gastric  symptoms ;  the  other,  a  long- 
continued  malady,  of  low  type,  with  its  characteristic  eruption 
and  enteric  signs.  It  is  only  when  yellow  fever  is  protracted 
beyond  the  ninth  day  that  the  diagnosis  is  rendered  doubtful ; 
and  then  we  have  generally  the  history  to  guide  to  a  correct  un- 
derstanding of  the  case.  The  likeness  between  yellow  fever  and 
typhus  is  much  closer.  But  one  is  a  short  fever,  with  distinct 
stages;  the  other  is  a  longer,  much  more  continued  fever.  One 
has  no  marked  cerebral  symptoms ;  in  the  other,  the  cerebral 
symptoms  are  the  most  prominent  feature.  One  has  but  rarely 
an  eruption,  but  often  hemorrhages;  the  other  has  always  an 
eruption,  and  hardly  ever  hemorrhages. 

The  disease  most  likely  to  be  confounded  with  yellow  fever  is 
bilious  remittent.  In  truth,  the  symptoms  are  very  similar,  and 
many  of  them  differ  only  in  intensity.  The  diagnosis  of  the  milder 
forms  of  yellow  fever  from  remittent  fever  is  indeed  extremely 
difficult,  unless  the  epidemic  influences  prevailing  be  taken  into 
account.  Then,  as  is  well  known,  the  affections  may  be  blended, 
and  yellow  fever  become  obviously  periodical  in  its  febrile  phe- 
nomena. The  occurrence  of  black  vomit  is  not  in  itself  a  distinc- 
tive sign  between  the  two  diseases;  for  black  vomit  may  be  absent 
in  yellow  fever,  and,  on  the  other  hand,  it  may,  although  it  rarely 
does,  occur  in  remittent  fever,  just  as  it  has  been  known  to  occur 
in  childbed  fever,  in  the  plague,  and  even  in  typhus  fever.* 

*  This  statement  with  reference  to  typhus  fever  is  made  on  the  authority 
of   Stokes.      The   occasional  occurrence  of  black  vomit  in   remittent  fever 


FEVEES. 


831 


The  least  doubtful  sign,  it  has  been  pointed  out,  is  derived  from 
an  examination  of  the  urine.  Unlike  what  happens  in  bilious 
fever,  albumen  appears  in  from  twelve  to  fourteen  hours  after  the 
fever  sets  in,  as  becomes  manifest  by  the  cloud  which  nitric  acid 
causes;  then  the  albumen  increases,  and  the  traces  of  urea  and 
the  uric  acid  diminish  and  gradually  disappear,  as  does  the  bile- 
pigment.*  The  more  obvious  the  suffusion  of  the  countenance  in 
yellow  fever,  the  more  marked  and  early  is  the  albuminuria.f 

When  yellow  fever  is  well  marked,  it  differs  in  this  way  from 
bilious  remittent : 


Yellow  Fever. 

Of  short  duration,  ending  commonly 

in  from  three  to  seven  days. 
Period  of  incubation  from  five  to  nine 


A  disease  of  one  paroxysm,  termi- 
nating in  recovery  or  in  collapse. 

Very  severe  nausea  and  vomiting 
throughout ;  early  and  decided  epi- 
gastric tenderness ;  black  vomit. 


Hemorrhages  from  gums  and  various 
parts  of  the  body. 

Tongue  clean,  or  but  slightly  coated  ; 
pulse  very  variable,  becomes  slow 
in  last  stages. 

Highly  injected,  humid  eye;  often 
fierce  or  anxious  expression  of  face. 

Supra-orbital  pain,  and  pain  in  back 
and  in  calves  of  the  legs. 

Very  rarely  delirium ;  mind  gener- 
ally clear. 


Bilious  Eemittent. 
Lasts  nine  days  or  upward. 

Period  of  incubation  very  variable ; 
may  extend  to  months. 

A  disease  of  several  paroxysms,  with 
intervening  remissions. 

Nausea  and  vomiting  not  so  severe, 
and  rarely  as  marked  at  the  onset ; 
neither  as  early  nor  as  constant 
and  decided  epigastric  tenderness ; 
vomiting  of  bile  and  of  the  con- 
tents of  the  stomach. 

No  hemorrhagic  tendency. 

Tongue  heavily  coated ;  pulse  varies 
less,  is  always  quick  until  convales- 
cence sets  in. 

Eye  not  peculiar ;  different  physiog- 
nomy. 

Headache  ;  sense  of  fulness  in  head  ; 
often  no  pain  in  loins  or  in  legs. 

Delirium  frequent ;  mind  always  dull. 


is  admitted  by  many  authors.  Some  winters  ago,  a  physician  of  this  city 
brought  to  me,  for  examination,  a  specimen  of  black  vomit  which  had  the 
same  microscopical  characters  that  I  have  repeatedly  found  in  the  black 
vomit  of  yellow  fever.  The  patient  undoubtedly  had  remittent  fever,  from 
which  he  recovered. 

*  Ballot,  Arch.  Gen.,  Nov.  1869  ;  see  also  an  elaborate  paper  on  the  Urine 
in  Yellow  Pever,  by  Joseph  Jones,  New  Orleans  Med.  and  Surg.  Journ., 
Jan.  1874;  and  Berenger-Feraud,  De  la  Fievre  jaune  a  la  Martinique,  Paris, 
1879. 

f  Bemiss,  loc.  cit. 


832  MEDICAL    DIAGNOSIS. 

Yellow  Fever.  Bilious  Kemittent. 

Urine   generally   contains   albumen;  No  albumen  in  urine ;  suppression  of 

suppression  of  urine  common.  urine  rare. 

Little    muscular    prostration;    often  Much  greater  muscular  prostration; 

rapid  convalescence ;  no  sequela?.  slow  convalescence  and  tedious  se- 
quelae. 

Almost  certain   immunity  after   one  One  attack  seems  rather  to  predispose 

attack.  to  others. 

Very  high  mortality  ;  disease  is  epi-  Slight   mortality ;    disease  more   en- 
demic, demic  in  its  nature. 

Treatment  unsatisfactory.  Very  amenable  to  treatment. 

Autopsy  shows  inflammation,  or  very  Autopsy    shows   congestion  of  stom- 

great  congestion,  of  stomach,  and  ach ;  more  rarely  a  high  degree  of 

sometimes  ulceration  or  softening.  inflammation.     Liver  of  an  olive  or 

Liver  enlarged,  of  a  yellowish  color,  bronze  hue,  not  fatty, 
its   secreting   cells   filled   with   oil- 
globules.     Heart  often  exhibits  dis- 
integration of  muscular  fibres. 

Eruptive  Fevers. 

The  eruptive  or  exanthematous  fevers  form  a  group  having 
numerous  features  in  common.  They  are  all  characterized  by  a 
period  of  incubation,  during  which  the  poison  lies  dormant  in 
the  system  ;  by  a  fever  of  more  or  less  intensity  preceding  the 
eruption  ;  by  an  eruption  which  presents  a  distinct  aspect  in  each 
disease,  and  which  pursues  a  definite,  clearly-defined  course  until 
it,  and  with  it  the  febrile  malady,  disappears.  Moreover,  they 
are  all  very  prone  to  occasion  serious  sequelae;  are  all,  in  the 
main,  disorders  of  childhood ;  rarely  attack  the  same  person 
twice;  and  are  contagious.  Their  origin  is  as  yet  unknown,  and 
their  prevention,  as  a  group,  uncertain.  One  of  them,  however, 
has  been  checked  in  its  ravages  by  a  wonderful  discovery  ;  and  it 
is  not  too  much  to  hope  that,  in  time,  all  will  be  brought  similarly 
under  the  control  of  science. 

These  remarks  apply  particularly  to  the  three  chief  exan- 
thematous fevers:  scarlet  fever,  measles,  and  smallpox.  In  great 
part,  too,  they  hold  good  in  regard  to  erysipelas,  described  here 
in  connection  with  the  eruptive  fevers. 

Scarlet  Fever. — This  disease,  known  also  as  scarlatina,  is 
one  of  the  gravest  of  the  exanthemata,  affecting  both  children 
and  adults,  and  is  marked  by  great  heat  of  skin,  frequent  pulse, 
sore  throat,  and  an  early  scarlet  eruption.     These  symptoms  are 


FEVEES.  833 

preceded  by  an  uncertain  period  of  incubation,  but  soon  exhibit 
their  striking  features.  The  febrile  excitement  is  characteristic ; 
the  skin  is  very  hot  and  generally  dry,  and  the  rapidity  of  the 
pulse  so  great  that  often  by  this  sign  alone  we  may,  especially  in 
the  midst  of  an  epidemic,  predict  the  coming  eruption.  Vomit- 
ing, too,  is  a  frequent  symptom  at  the  beginning  of  the  illness. 

The  rash  appears  on  the  second  day  of  the  disease.  It  comes 
out  almost  simultaneously  all  over  the  body,  although,  on  close 
scrutiny,  it  may  be  soonest  perceived  on  the  neck  and  breast.  At 
first  the  surface  exhibits  an  almost  uniform  red  blush,  which 
disappears  momentarily  on  pressure,  or  rather  pressure  leaves  a 
white  stain  on  the  skin,  which  quickly  again  reddens  from  the 
periphery  to  the  centre.  Soon,  however,  the  eruption  presents  an 
unequal  aspect :  it  is  of  more  vivid  scarlet  hue  in  some  parts  of 
the  body,  as  in  and  around  the  flexures  of  the  joints,  and  is  not 
everywhere  smooth.  Here  and  there  are  seen  elevated  rough 
points  of  darker  tint,  edged  by  the  red  integument,  and  not 
unfrequently  vesicles  containing  a  thin  fluid.  The  skin  is  very 
hot  and  itchy,  and  tumefied,  especially  on  the  hands  and  feet. 
The  eruption  declines  on  the  fourth  or  the  fifth  day ;  by  the 
seventh,  the  cuticle  begins  to  come  away  in  large  flakes.  Some- 
times the  rash,  when  at  its  height,  recedes  and  then  appears  again. 
In  malignant  cases  it  comes  out  late,  and  is  either  pale  and  indis- 
tinct or  dark  and  livid.  In  some  instances  it  is  wholly  wanting. 
Some  years  ago,  I  saw  a  case  of  this  "scarlatina  sine  exanthemate" 
in  a  lady,  who,  watching  over  the  sick-bed  of  her  daughter,  con- 
tracted the  disease  and  went  regularly  through  it,  even  to  its 
sequelae  of  disorder  of  the  kidneys  and  swelling  of  the  salivary 
glands,  but  in  whom  not  a  trace  of  an  eruption  could  be  detected. 

The  sore  throat  of  scarlatina  is  almost  as  constant  and  as  char- 
acteristic as  the  scarlet  rash.  It  shows  itself  early,  sometimes 
before  the  eruption,  and  rarely  waits  until  the  third  day  of  the 
complaint.  At  first  the  throat- affection  consists  in  a  diffused 
redness  extending  over  the  tonsils,  palate,  and  half-arches,  and 
in  a  swelling  of  the  tonsils :  the  patient  complains  of  pain  in  his 
throat,  augmented  by  pressure  and  by  swallowing,  and  of  stiffness 
of  the  muscles  of  the  neck.  After  a  few  days,  if  the  disorder 
be  severe,  irritating  discharges  occur  from  the  inflamed  surfaces, 
and   patches  of  false  membrane  and  superficial  ulcerations  are 

53 


834  MEDICAL    DIAGNOSIS. 

seen  in  the  fauces.  The  glands  at  the  angle  of  the  jaw  become 
much  tumefied,  and,  by  pressing  on  the  cervical  vessels,  produce  a 
tendency  to  drowsiness  and  stupor.  These  are  grave  symptoms; 
their  occurrence,  indeed,  is  indicative  of  one  of  the  main  dangers 
in  these  "  anginose"  cases  of  the  disease. 

The  false  membranes  which  are  developed  last  about  five  or  six 
days;  they  form  as  well  as  reform  in  patches,  and  are  very  easily 
removed.  Sometimes  they  extend  to  the  larynx;  but  this  does 
not  often  happen,  and  even  when  it  does,  the  symptoms  of  croup, 
in  the  opinion  of  Barthez  and  Rilliet,  do  not  arise.  The  acrid 
discharges  and  the  decomposing  membranes  often  occasion  a  most 
fetid  breath,  and,  by  being  swallowed,  a  persistent  diarrhoea. 

The  tongue  has  a  peculiar  look.  At  first  it  is  thickly  coated, 
and  its  borders  only  are  red ;  but  soon  the  fur  is  cast  off,  and 'the 
whole  organ  becomes  very  red  and  its  papillae  prominent.  After 
it  has  presented  this  appearance  for  six  or  eight  days,  it  returns 
to  its  normal  condition.  In  bad  cases  it  is  extremely  dry  and  of 
a  brownish  hue. 

In  children,  the  disease  frequently  sets  in  with  convulsions.  In 
truth,  cerebral  symptoms  of  one  kind  or  another  are  not  uncommon 
at  all  stages  of  the  malady ;  yet  great  differences  are  observed,  in 
this  respect,  in  different  epidemics.  In  some  cases  of  malignant 
character,  the  vomiting,  the  screams,  the  grinding  of  the  teeth, 
the  occurrence  of  delirium  and  insomnia,  make  the  attack  look, 
at  the  onset,  like  one  of  acute  meningitis ;  but  the  eruption  soon 
sets  all  doubt  at  rest,  and,  even  before  it  is  noticed,  the  great  heat 
of  the  skin  and  the  extreme  rapidity  of  the  pulse  point  to  the 
source  of  the  mischief.  The  nervous  symptoms  in  these  dangerous 
instances  of  the  affection  do  not,  however,  cease  with  the  eruption; 
they  may  last  to  the  end  of  the  malady.  Sometimes  they  are  not 
noticed  until  late  in  the  disorder,  and  after  the  period  of  desqua- 
mation has  fully  begun ;  but  the  convulsions  and  stupor — for 
these  are  the  morbid  manifestations  then  more  specially  encoun- 
tered— are  owing  rather  to  a  diseased  state  of  the  kidneys  that  has 
been  induced,  than  to  the  immediate  effect  of  the  fever  poison. 

Occasionally  some  of  the  larger  joints  swell  up,  and  present 
the  appearance  of  subacute  rheumatism.  The  joints  are  not, 
however,  very  painful  on  pressure,  and  generally  only  two  or 
three  are  enlarged.     This  form  of  rheumatism  is  evidently  owing 


FEVERS.  835 

to  the  retention  in  the  blood  of  some  morbid  material,  and  would 
seem  to  simulate  ordinary  acute  articular  rheumatism  in  present- 
ing endocarditis  and  pericarditis  as  complications.* 

Further  complications  of  the  disease  are  dropsies,  passage  of 
blood  from  the  kidneys,  pleurisy,  tendency  to  gangrene,  oedema 
of  the  glottis,  diphtherial  and  a  very  low  state  of  the  system. 
These  complications  are  not  apt  to  arise  until  at  or  soon  after  the 
period  of  desquamation;  sometimes  they  lead  to  long-continued 
disorder,  and  become  thus  the  most  hazardous  of  the  sequelae. 
Other  consequences  of  the  affection,  lasting,  it  may  be,  for  years 
after  the  febrile  attack,  are  a  tendency  to  boils,  swelling  of  the 
parotid  and  of  the  lymphatic  glands  of  the  neck,  diarrhoea, 
chronic  inflammation  of  the  eyelids,  and  deafness  from  inflam- 
mation extending  up  the  Eustachian  tube  to  the  membrane  of 
the  tympanum,  or  from  suppurative  destruction  of  portions  of 
the  ear. 

Of  all  these  morbid  states,  dropsy  is  the  most  common.  The 
effusion  of  fluid  may  be  caused  by  the  altered  state  of  the  blood ; 
but  much  more  generally  it  is  owing  to  the  poison  producing  an 
acute  desquamative  nephritis :  the  secreting,  function  of  the  kid- 
neys is  impaired ;  albumen,  tube-casts,  epithelial  cells,  and  some- 
times blood,  are  found  in  the  urine;  and  we  meet  with  severe 
headache,  great  restlessness,  and  oedema  of  the  face  and  extremi- 
ties, as  the  attending  symptoms.  Still,  notwithstanding  these 
grave  phenomena,  the  majority  of  the  cases  recover,  and  the 
kidneys  are  rarely  permanently  injured. 

The  dropsy  is  apt  to  show  itself  between  the  tenth  and  the  twen- 
tieth day  of  the  malady.  The  albuminous  condition  of  the  urine 
may  precede  it  by  several  days ;  yet  dropsy  may  happen  without 
albuminuria,  especially  in  some  epidemics,!  and  albumen  in  the 
urine  is  not  always  associated  with  dropsy.  In  most  cases  of  scar- 
latina it  is  found  at  some  period  of  the  disease  for  a  short  time 
and  in  small  quantities;  but  this  transitory  albuminuria  is  not, 
like  the  albuminuria  coexisting  with  marked  anasarca,  connected 
with  many  tube-casts  in  the  urine  and  numerous  epithelial  cells. 


*  Scott  Alison,  Medical  Gazette,  1845. 

f  Trousseau,  Clinique  Medicale,  tome  i. 

%  Gee,  in  Russell  Reynolds's  System  of  Medicine. 


836  MEDICAL    DIAGNOSIS. 

The  state  of  exhaustion  noticeable  at  the  close  of  the  fever  and 
while  desquamation  is  still  going  on  is  at  times  great, — so  great 
that,  in  young  persons  especially,  the  case  wears  the  look  of  ty- 
phoid fever.  And  the  resemblance  is  heightened  by  the  occur- 
rence of  diarrhoea  associated  with  a  swelling  of  the  solitary  and 
agminated  glands.  But  the  signs  of  desquamation,  the  sore  throat, 
the  enlargement  of  the  cervical  glands,  and  the  history  of  the 
aifection  furnish  distinctive  marks  of  the  utmost  value. 

The  allusions  that  have  just  been  made  to  the  diverse  compli- 
cations of  the  malady  are  mainly  of  interest  on  account  of  their 
exhibiting  the  intricate  diagnostic  questions  which  may  arise.  Of 
the  recognition  of  the  disorder  during  the  febrile  stage  it  is  not 
necessary  to  say  much,  as  ordinarily  it  is  not  difficult.  The  dis- 
tinction between  it  and  the  other  exanthematous  fevers  may  be 
seen  by  glancing  at  the  table,  to  which  a  place  is  elsewhere  assigned, 
showing  their  similitudes  and  their  differences.  I  shall  only  here 
mention,  as  bearing  upon  the  distinction  between  scarlet  fever  and 
measles,  that  cases  are  occasionally  encountered  in  which  the  erup- 
tion alone  is  too  ill  defined  to  become  the  sole  basis  of  an  opinion, 
and  that  then  we  have  to  lay  the  greatest  stress  on  the  presence  or 
absence  of  catarrhal  symptoms  and  sore  throat,  and  on  the  march 
of  the  symptoms.  So,  too,  with  reference  to  smallpox.  The 
rash  preceding  the  formation  of  the  pustules  may  have  so  strong 
a  resemblance  to  that  of  scarlet  fever  that  a  scrutiny  of  all  the 
attending  circumstances,  and  a  careful  watching  of  the  eruption 
for  at  least  a  day,  are  requisite  to  the  detection  of  the  true  nature 
of  the  case.* 

An  erythematous  rash,  appearing  in  blotches  everywhere  ex- 
cept on  the  face,  has  been  noticed  in  membranous  croup  and  in 
laryngeal  diphtheria  after  the  operation  of  tracheotomy.!  But 
it  is  very  irregular,  runs  a  rapid  course,  and  is  not  followed  by 
desquamation ;  a  point,  it  may  be  here  mentioned,  distinguishing 
all  the  forms  of  irregular  rashes,  happening  at  times — though 
very  rarely — in  diphtheria,  from  the  scarlet  fever  eruption. 

Like  measles,  scarlatina  may  be  mistaken  for  that  curious  form 


*  The  disorders  may  also  be  combined.     See  the  cases  of  Marson,  Medicd- 
Chirurg.  Trans.,  vol.  xxx. 

f  Bericht  des  K.  K.  Krankenhauses  Wieden,  180-3. 


FEVEES.  837 

of  eruptive  fever  now  called  rubeola.  But  this  really  more  closely 
resembles  measles,  and  in  examining  it  presently  the  differences 
between  it  and  scarlet  fever  will  become  apparent. 

An  affection  with  several  features  corresponding  to  scarlatina 
is  the  breakbone  fever,  or  dengue.  The  points  of  dissimilarity 
may  be  learned  by  referring  to  the  description  of  the  malady 
farther  on  given. 

Measles. — The  symptoms  precursory  to  the  specific  eruption 
of  this  affection  are  fever,  watery  eyes,  frequent  sneezing,  flow 
from  the  nose,  and  cough ;  in  fact,  all  the  manifestations  of  an 
acute  coryza  or  catarrh.  To  these  diarrhoea  is  in  many  instances 
added,  indicating  a  simultaneous  irritation  of  the  intestinal  mucous 
membrane.  On  the  fourth  day  after  the  beginning  of  the  morbid 
signs,  a  rash  is  perceived  on  the  face  and  neck ;  thence  it  con- 
tinues to  extend,  until,  in  the  course  of  two  or  three  days,  the 
whole  body  is  covered.  The  eruption  does  not  alleviate  the  febrile 
symptoms;  on  the  contrary,  while  it  is  spreading  to  the  trunk 
and  lower  extremities,  the  constitutional  disturbance  increases. 
But  as  soon  as  it  begins  to  fade,  which  it  does  on  the  third  or  the 
fourth  day  of  its  appearance,  the  fever  lessens ;  and  by  the  ninth 
day  of  the  disease  both  fever  and  rash  have  left.  Frequently 
then  the  cuticle  comes  away  in  fine  scales,  and  this  desquamation 
is  attended  with  very  annoying  itching.  The  patient,  now  that 
he  is  convalescent,  shows  his  illness :  he  is  pale  and  somewhat 
emaciated.  Often  he  still  coughs,  and  his  eyes  are  slightly  in- 
flamed.    These  signs  are  not  unusually  the  last  to  disappear. 

Of  all  the  symptoms  mentioned,  two  are,  in  a  diagnostic  sense, 
of  pre-eminent  importance :  the  catarrh  and  the  eruption. 

The  catarrh  is  nearly  constant.  It  is  true  that  a  variety  of 
measles  is  recognized — "rubeola  sine  catarrho;"  but  this  is  very 
rare.  Generally  speaking,  the  coryza  and  catarrh  decline  with 
the  eruption ;  occasionally,  however,  they  remain  for  some  time 
after  the  rash  has  left.  The  feature  which  distinguishes  these 
catarrhal  symptoms  from  those  of  influenza  consists  in  the  erup- 
tion :  before  this  happens,  the  diagnosis  is  uncertain,  though  we 
may  often  suspect  measles  by  the  look  of  the  face,  the  greater 
intensity  of  the  febrile  signs,  and  the  knowledge  that  the  disease 
is  prevailing  in  the  community. 

The  eruption  is  peculiar :  it  consists  of  slightly-raised  red  spots, 


838  MEDICAL    DIAGNOSIS. 

which  coalesce  and  form  blotches  of  an  irregular,  crescentic  shape ; 
between  these  blotches  the  skin  is  of  natural  color.  The  erup- 
tion disappears  first  from  the  face;  in  other  words,  it  disappears 
in  the  same  order  in  which  it  appeared.  As  it  fades,  it  becomes 
brownish,  and  subsequently  of  a  yellowish  tint.  In  its  earliest 
stages  it  is  similar  to  the  papulae  of  smallpox;  and  this  similarity 
may  be  heightened  by  its  being  mixed,  as  it  sometimes  is,  with  a 
few  miliary  vesicles.  But  after  the  first  day  of  the  rash  there  is 
little  room  for  doubt.  In  the  one  case  the  spots  remain  as  they 
were ;  in  the  other,  they  change  into  pustules. 

A  question  may  sometimes  ari-e  as  to  whether  the  eruption  be 
that  of  typhus  fever  or  of  measles.  Both  are  coarse,  both  often 
not  unlike  in  color,  and  both  may  be  developed  about  the  same 
time.  Generally  speaking,  however,  the  eruption  of  typhus  fever 
shows  itself  several  days  later  than  the  rash  of  measles;  and, 
although  coarse,  it  is  not  crescentic,  and  is  found  on  the  trunk 
and  extremities  rather  than  upon  the  face.  Moreover,  the  physi- 
ognomy, the  excessive  prostration  of  strength,  and  the  marked 
cerebral  symptoms  of  the  low  fever  are  such  as  to  render  a  dif- 
ferential diagnosis  seldom  difficult. 

Measles  is  usually  met  with  in  children  ;  but  it  may  be  en- 
countered in  adults,  especially  among  soldiers,  and  is  in  adults  a 
much  more  severe  complaint  than  in  children.  In  the  latter  it  is 
not  an  alarming  disease.  Only  occasionally  does  it  occur  in  epi- 
demics which  present  a  malignant  character.  Its  greatest  danger 
commonly  consists  in  the  eruption  disappearing  prematurely  or 
appearing  but  partially,  and  in  the  severity  of  the  thoracic  com- 
plications.    These  are  either  acute  bronchitis  or  acute  pneumonia. 

Acute  bronchitis  may  occur  at  any  period  of  the  disorder,  and 
involve  the  finer  tubes.  But  it  does  not  generally  set  in  with 
severity  until  the  eruption  has  reached  its  height  or  is  beginning 
to  fade.  In  young  children,  symptoms  of  inflammation  of  the 
larynx,  or  of  croup,  are  at  the  same  period  apt  to  manifest  them- 
selves. Acute  inflammation  of  the  lung,  too,  either  croupous  or 
catarrhal,  the  latter  quite  often,  is  met  with  at  this  stage  of  the 
malady,  or  sometimes  even  after  convalescence  has  apparently 
begun.  We  may  suspect  that  mischief  is  going  on  within  the 
chest,  if  the  breathing  be  very  oppressed  and  the  pulse  continue 
to  be  rapid;  but,  so  as  to  detect  early  the  hazardous  and  insidious 


FEVERS.  839 

complication,  we  have  to  depend  chiefly  on  physical  exploration 
of  the  whole  chest.  Occasionally  the  thoracic  affection  leaves  a 
chronic  bronchial  disease,  or  a  persistent  cough  and  night-sweats 
point  to  the  development  of  tubercles.  It  may,  in  individual 
cases,  be  extremely  difficult  to  decide  with  which  of  these  morbid 
states  we  have  to  deal.  Emaciation  and  a  chronic  cough  are 
found  in  both  chronic  bronchitis  and  phthisis ;  and  the  physical 
signs  of  tubercular  consumption  are,  in  children,  notoriously  ill 
defined  and  untrustworthy.  Then,  the  nummular  sputum  may 
occur  in  the  bronchitis  of  measles.  We  may,  therefore,  be  obliged 
to  await  the  progress  of  the  abnormal  phenomena  before  coming 
to  a  definite  conclusion. 

At  times  we  meet  with  anomalous  forms  of  measles.  There  is 
a  kind  of  measles  with  a  papular  eruption  like  ordinary  measles, 
but  distinguished  from  it  by  the  papulae  not  being  arranged  in 
crescentic  clusters,  being  less  obvious,  and  not  appearing  at  all,  or 
showing  themselves  but  imperfectly,  on  the  limbs.  The  patches 
are  of  dusky  hue,  and  there  is  no  distinct  sore  throat,  but  con- 
siderable constitutional  disturbance.  This  "  rubeola  notha"  pre- 
vailed extensively  in  London  some  years  since.*  A  somewhat 
similar  anomalous  exanthem  was  common  in  Philadelphia  during 
the  winter  of  1865-1866,  occurring  at  a  time  when  both  measles 
and  scarlatina  were  frequent,  and  particularly  the  former.  The 
eruption,  more  partially  papular  than  that  of  measles,  but  of  dark 
hue  like  it,  was  principally  confined  to  the  face.  It  appeared  at 
the  end  of  the  first  or  on  the  second  day  of  a  slight  malaise; 
though  in  some  instances  I  saw  there  had  been  a  marked  chill  at 
the  beginning  of  the  complaint,  in  others  the  rash  was  the  first 
sign  of  disease  attracting  attention.  There  was  little  constitutional 
disturbance,  a  slight  watery  appearance  of  the  eye,  no  sore  throat, 
or  a  mere  faucial  reddening,  and  cough;  but  this  symptom  was 
not  constant.  The  eruption,  which  occurred  chiefly  in  patches, 
not,  however,  distinct  and  crescentic,  lasted  from  five  to  seven  days, 
gradually  fading,  and  not  being  followed  by  desquamation.  In 
only  one  instance  did  I  observe  a  peeling  of  the  cuticle,  and  this 
happened  on  the  hands  and  feet.  An  almost  invariable  sequel 
was  swelling  of  the  cervical  glands.     The  urine  in  the  cases  I 

*  Babington,  Lancet,  May  7,  1864. 


840  MEDICAL    DIAGNOSIS. 

examined  contained  no  albumen,  and  convalescence  was  rapid. 
In  one  family  I  attended,  the  exanthem  attacked  three  out  of 
four  children,  all  of  whom  had  had  measles  two  years  previously. 

Perhaps  these  anomalous  forms  of  measles  are  rather  varieties 
of  rubeola  than  of  measles.  An  affection  formerly  very  com- 
mon, miliary  fever,  would  be  also  a  source  of  much  confusion 
were  it  in  our  day  often  encountered.  But  epidemics  of  miliaria 
are  now  extremely  rare.  Yet  we  know  that  it  is  a  disorder  with  a 
prodromal  stage  of  two  or  three  days,  during  which  great  irrita- 
tion of  the  skin,  debility,  and  a  feeling  of  suffocation  are  usual. 
The  marked  disease  begins  with  profuse  sweating  and  with  severe 
fever,  and  precordial  and  epigastric  distress.  These  symptoms 
last  until  the  appearance  of  the  rash,  generally  on  the  third  or  the 
fourth  day,  though  sometimes  not  until  much  later,  and  then,  as 
a  rule,  slowly  subside.  The  rash  appears  first  upon  the  neck 
and  the  breast,  and  consists  of  numerous  round  or  irregular  spots 
in  the  centre  of  which  vesicles  arise  that  finally  burst  and  form 
crusts.  The  disease  ends  with  desquamation  and  generally  in 
a  slow  convalescence.  The  sweating,  the  oppression  and  pre- 
cordial pain,  and  the  peculiar  eruption  distinguish  chiefly  this 
epidemic  disease  from  measles. 

Rubeola. — The  most  striking  resemblance  to  measles  is  fur- 
nished by  rubeola.  This,  also  called  by  the  Germans  rotheln,  or 
"fire-measles,"  and  often  spoken  of  as  "German  measles"  or 
"  French  measles,"  is  regarded  by  some  as  roseola,  but  more  gen- 
erally as  a  hybrid  of  measles  and  scarlet  fever,  or  as  a  special  exan- 
them ;  and  this  view  of  the  case  is  being  now  generally  adopted. 
The  disease  occurs  particularly  in  epidemics.  It  displays  a  red 
eruption,  ushered  in  by  a  chill,  followed  by  slight  fever,  which  is 
accompanied  by  coryza,  cough,  and  sore  throat.  The  fever  prior 
to  the  eruption  lasts  for  two  or  three  days,  but  this  is  far  from  con- 
stant ;  indeed,  it  often  does  not  last  more  than  half  a  day.  The  rash 
may  come  out  all  over  at  once,  or  spread  in  a  day  or  two  over  the 
body  ;  it  generally  appears  first  on  the  face.  It  is  most  distinct  on 
the  face,  the  scalp,  the  neck,  and  the  trunk,  being  more  scattered  on 
the  extremities;  it  is  specially  distinct  about  the  mouth.  It  first 
resembles  measles,  but  the  spots  are  round  or  oval,  and  smaller  and 
paler,  and  they  soon  run  together  in  irregular  patches,  unlike  the 
well-defined  crescentic  eruption  of  measles;  they  show  no  tendency, 


FEVERS.  841 

however,  to  become  very  generally  confluent.  The  patches  are  of 
variable  size,  and,  unlike  the  rash  of  scarlatina,  are  surrounded  by 
healthy  skin ;  small  spots  range  themselves  around  the  large  ones. 
They  are  of  deepest  color  in  the  centre,  but  not  bright-colored  as 
in  measles,  nor  of  the  dark  red  of  severe  scarlatina,  are  elevated, 
and  very  much  influenced  by  pressure.  The  eruption  lasts  ordi- 
narily four  days,  but  in  severe  cases  eight  or  ten.  It  gradually 
fades,  but  it  may  happen  that  it  fades  on  the  face  before  it  has 
fairly  come  out  on  the  legs,  and  desquamation  may  ensue,  though 
the  scales  are  small,  and  never  in  size  like  those  of  scarlet  fever. 
During  the  continuance  of  the  rash,  which  is  attended  with  much 
itching,  the  general  symptoms  are  much  aggravated,  except  the 
fever,  which  indeed  may  only  be  at  all  perceptible  at  the  begin- 
ning of  the  affection;  the  sore  throat  and  catarrh  may  be  severe, 
and  attended  with  hoarseness  and  with  inability  to  swallow  ;  there 
is  congestion  of  the  conjunctivae  and  pain  in  the  eyes.  As  the 
eruption  fades,  the  constitutional  symptoms  subside.  Swelling, 
and  even  suppuration,  of  the  cervical  glands,  are  not  uncommon 
sequelae. 

The  disease  is  contagious,  and  affects  especially  children ;  it  is 
extremely  uncommon  after  forty  years  of  age.  Second  attacks  are 
also  very  rare. 

Smallpox, — This  fearful  disease,  which  formerly  ravaged  all 
parts  of  the  globe,  is  now,  fortunately,  very  rarely  encountered 
in  civilized  countries  in  those  frightful  epidemics  so  dreaded  and 
so  disastrous  to  the  human  race. 

Smallpox,  or  variola,  attacks  both  children  and  adults.  It  is 
a  highly  contagious  malady,  spreading  very  rapidly  among  those 
unprotected  by  vaccination,  and  among  masses  of  men :  hence  its 
presence  on  board  ship  or  in  camps  is  especially  to  be  feared. 

The  chief  symptoms  of  the  stage  of  invasion  are  chills,  fever, 
and  pain  in  the  back.  The  fever  runs  very  high,  and  exacerbates 
markedly  toward  evening.  The  pain  in  the  back  is  severe,  and 
particularly  severe  in  grave  cases;  there  are  also  nausea,  vomiting, 
headache,  and  great  restlessness.  All  these  symptoms  subside  at 
the  end  of  the  third  or  on  the  fourth  day,  when  an  eruption  shows 
itself  on  the  lips  and  forehead,  and  soon  extends  to  the  trunk,  and 
from  the  trunk  to  the  extremities. 

At  first  the  eruption  has  the  appearance  of  papula? ;  but  on  the 


842  MEDICAL    DIAGNOSIS. 

second  and  third  days  the  coarse  spots  undergo  a  decided  change. 
At  the  top  of  each  papule  appears  a  vesicle,  which  gradually  be- 
comes larger  and  larger  and  fills  up  with  a  milky,  thick  fluid ;  in 
short,  becomes  a  pustule.  By  the  fifth  or  sixth  day  this  change 
has  been  fully  accomplished,  and  the  pustules  are  spheroidal  and 
lose  the  umbilicated  look  which  they  had  while  forming.  On  the 
eighth  day  matter  begins  to  ooze  from  their  edges,  and  a  second- 
ary fever  sets  in,  lasting  for  three  or  four  days, — until,  indeed,  all 
the  pustules  are  broken  ;  this  secondary  fever  is  sometimes  ushered 
in  by  a  chill ;  it  is  of  remittent  type,  and  the  evening  temperature 
marks  between  102°  and  104°.  By  the  time  it  subsides,  crusts 
form  where  previously  there  had  been  pustules ;  and  as  these  crusts 
dry  and  fall  off,  the  skin  beneath  is  seen  to  be  of  a  red  color,  which 
only  very  gradually  fades,  and  here  and  there  are  noticed  those 
scars  and  pits  which  the  patient  carries  during  the  remainder  of 
his  life. 

When  the  pustules  are  in  great  abundance,  they  run  together; 
such  cases  are  very  grave,  and  constitute  the  variety  of  the  dis- 
ease known  as  confluent  smallpox.  The  eruption  may  be  discov- 
ered a  day  earlier  than  in  the  discrete  form,  and  the  rough,  red 
blotches  are  often  so  thickly  clustered  as  to  give  a  uniformly  red 
aspect  to  the  whole  surface.  When  the  pustules  completely  fill 
up,  whole  portions  of  the  face  or  of  the  trunk  seem  to  be  covered 
by  one  extensive  pustule,  which  gradually  dries  into  a  continuous 
brownish  and  most  disfiguring  crust.  While  the  process  of  matu- 
ration is  going  on,  the  features  are  observed  to  be  greatly  swollen ; 
the  eyes  may  be  hidden  from  view ;  the  nose  and  lips  are  tumid. 
The  patient  complains  of  the  tension  of  the  skin  ;  and  not  unfre- 
quently  of  sore  throat  and  of  a  steady  flow  of  saliva  from  the 
mouth.*  The  secondary  fever  is  violent,  far  more  so  than  in 
discrete  variola.  It  may  not  show  itself  until  a  day  or  two  later, 
but  lasts  longer,  shows  a  higher  temperature,  and  is  the  period  of 
danger,  since  it  is  at  this  time  that  death  is  most  apt  to  happen. 

A  fatal  issue  is  often  preceded  by  a  dry  tongue,  by  delirium,  and 
by  great  restlessness ;  by  what,  in  fact,  are  called  typhoid  symp- 


*  Salivation  may  also  be  met  with  in  measles,  and  sometimes  in  other 
acute  affections.  Thus,  Tilt  (Change  of  Life,  3d  edit.)  tells  us  that  he  has 
observed  it  in  connection  with  intense  cerebral  neuralgia  in  women  whose 
menstrual  functions  are  ceasing. 


FEVERS.  843 

toms.  Sometimes  it  is  brought  about  by  attacks  of  dysentery  or 
of  diarrhoea,  by  passive  hemorrhages,  by  affections  of  the  larynx 
or  trachea,  or  by  acute  endocarditis  ;*  by  some  complications, 
therefore,  which  the  worn  and  irritated  frame  is  unable  to  with- 
stand. Now  and  then  death  takes  place  from  supervening  pleu- 
'risy  or  pneumonia  or  bronchitis;  but  an  unfortunate  termination 
from  maladies  of  the  respiratory  organs  does  not  occur  only  in  the 
secondary  fever,  as  these  affections  are  also  encountered  during 
the  period  of  eruption.  Sometimes  the  patient  sinks  at  the  very 
onset  of  the  disease.  In  these  malignant  cases  he  dies  from  the 
virulence  of  the  poison.  He  is  stupid,  delirious;  the  eruption 
seems  as  it  were  to  struggle  to  reach  the  surface,  is  of  a  livid  hue, 
and  may  fail  to  appear  until  after  death. 

Smallpox  is  occasionally  met  with  during  the  progress  of 
other  disorders,  blending  its  symptoms  with  those  of  the  com- 
plaint to  which  it  becomes  superadded.  It  is  thus  found  as  an 
intercurrent  affection  in  typhoid  fever,  in  typhus,  in  scarlet  fever, 
and  in  measles  ;  yet  even  then  there  is  no  difficulty  in  recognizing 
its  peculiar  traits, — its  lumbar  pain  and  characteristic  eruption. 
Ordinarily  the  detection  of  variola  is  extremely  easy,  except  at  its 
onset.  But  the  points  of  similarity  it  may  present,  in  its  early 
stages,  to  typhus  fever,  to  erysipelas,  and  to  several  other  diseases, 
have  been  already  discussed  and  need  not  be  repeated ;  elsewhere 
it  has  been  noticed  that  we  have  often  to  wait  the  course  of  the 
eruption  before  framing  a  positive  diagnosis  from  the  symptoms 
alone,  and  without  taking  the  epidemic  influences  prevailing  into 
account.  When  the  disorder  is  fully  developed,  all  difficulty  in 
its  diagnosis  ceases.  Let  us  here  look  at  the  marks  of  distinction 
between  it  and  the  other  principal  eruptive  fevers,  premising  the 
statement  that,  in  the  period  of  invasion,  the  pain  in  the  loins  is 
the  most  significant  differential  sign  : 

Table  exhibiting  the  Differences  between  Scarlet  Fever, 

Measles,  and  Smallpox. 
Scarlet  Fever.  Measles.  Smallpox. 

Period  of  incubation  Period  of  incubation  Period  of  incubation 
very  uncertain ;  may  variable ;  generally  from  sis  to  twenty 
be  only  a  day.  or  may  from  seven  to  four-  days  ;  generally  about 
be  weeks.  teen  days.  ten  days. 

*  Quinquad,  Arch.  Gen.  de  Med.,  Sept.  1870. 


844 


MEDICAL,    DIAGNOSIS. 


Table  exhibiting  the  Differences  between  Scarlet  Fever, 
Measles,  and  Smallpox — Continued. 


Scarlet  Fever. 
Fever,    with    very    fre- 
quent  pulse ;    persists 
unabated  during  erup- 
tion. 

Eruption  on  second  day, 
first  on  neck  and  chest ; 
spreads  rapidly. 


Eruption  uniform  or  in 
very  large  patches  of 
scarlet  hue,  with  in- 
terspersed raised  spots 
and  some  vesicles ; 
rash,  followed,  after 
the  seventh  day  from 
its  appearance,  by 
very  complete  desqua- 
mation. 

Sore  throat ;  rarely  co- 
ryza  or  bronchitis. 

Red  "raspberry" 
tongue. 

Cerebral  symptoms  fre- 
quent and  grave. 

Temperature  very  high  ; 
may  range  from  105° 
to  112° ;  no  rapid  fall 
soon  after  eruption, 
nor  decided  increase  of 
heat  preceding  it ;  high 
temperature  —  though 
not  so  high  as  at  first 
or  at  height  of  erup- 
tion— to  the  tenth  day, 
when  it  begins  to  sub- 
side gradually.  Ac- 
cording to  Ringer,  a 
fall  of  temperature 
takes  place  on  the  fifth, 
tenth,     and     fifteenth 


Measles. 

Fever,  with  moderate 
frequency  of  pulse ; 
not  relieved,  but 
rather  increased,  by 
eruption. 

Eruption  on  fourth  day, 
first  on  face ;  spreads 
gradually,  in  course 
of  about  forty-eight 
hours,  to  rest  of  body. 

Eruption  in  crescentic 
patches,  with  inter- 
vening portions  of 
healthy  skin ;  lasts 
about  five  days  ;  fol- 
lowed by  partial  and 
very  incomplete  des- 
quamation, and  scales 
are,  as  a  rule,  very 
fine. 

Coryza  and  bronchitis 
very  constant ;  rarely 
sore  throat. 

Tongue  coated  ;  may  be 
red  at  edges. 

Cerebral  symptoms 

neither  frequent  nor 
grave. 

Temperature  during  the 
fever  preceding  erup- 
tion high,  from  103° 
to  106°  ;  rises  rapidly 
toward  breaking  out 
of  eruption.  It  may 
remain  high  for  from 
twelve  to  twenty-four 
hours  after  appear- 
ance of  rash ;  then 
sinks  very  speedily, 
a  return  to  almost  a 
normal  temperature 
being  arrived  at  on 
the  second  day  from 
the   beginning    of   its 


Smallpox. 

Fever,  with  bounding 
pulse,  and  pain  in  the 
loins ;  great  relief 
from  occurrence  of 
eruption. 

Eruption  at  end  of  third 
or  on  fourth  day ;  first 
on  lips  and  forehead. 


Eruption  first  papular ; 
remains  so  about  a 
day ;  then  becomes 
vesicular,  then  pustu- 
lar ;  on  the  eighth  day 
of  eruption,  pustules 
maturate. 


Often  sore  throat  and 
dry  cough  ;  bronchitis 
only  as  a  complication. 

Tongue  coated  and  swol- 
len ;  may  become  red 
at  edges. 

Cerebral  symptoms,  es- 
pecially convulsions  in 
children,  frequent. 

Temperature  during  the 
fever  preceding  erup- 
tion, often  106°  ;  then 
speedy  defervescence, 
taking  place  within 
thirty-six  hours ;  sub- 
sequently thermom- 
eter indicating  a  tem- 
perature of about  100°, 
notwithstanding  the 
progressing  develop- 
ment of  the  pimples 
into  pustules.  De- 
cided rise  of  tempera- 
ture during  secondary 
fever,  and  then  grad- 


FEVERS. 


845 


Table  exhibiting  the  Differences  between  Scarlet  Fever, 
Measles,  and  Smallpox — Continued. 


Scarlet  Feter. 
days    of    the   disease. 
Irregular   cases   have 
irregular,  though 

mostly  very  high,  tem- 
perature. 


No  secondary  fever. 


Pneumonia  rare ;  pleu- 
risy more  frequent. 

Sequelae :  Bright's  dis- 
ease ;  dropsy ;  con- 
junctivitis ;  deafness  ; 
phthisis;  chronic  diar- 
rhoea ;  glandular  en- 
largements. 


Measles. 
fall.  Thus  the  de- 
fervescence is  hoth 
rapid  and  complete. 
A  protracted  defer- 
vescence, or  the  max- 
imum of  temperature 
lasting  for  a  consid- 
erahle  time  after  the 
coming  out  of  the 
eruption,  or  a  high 
degree  prior  to  it,  in- 
dicates a  severe  case; 
a  high  temperature 
after  it  has  faded  is 
due  to  a  complication. 

No  .  secondary  fever  ; 
although  sometimes 
a  slight  increase  of 
fever  just  before  erup- 
tion leaves. 

Pneumonia  a  very  fre- 
quent complication. 

Sequelae :  chronic  bron- 
chitis ;  phthisis ;  con- 
junctivitis. 


Smallpox. 
ual  and  protracted  de- 
fervescence ;    a   slight 
rise     during    desicca- 
tion.    (Wunderlich.) 


Always  secondary  fever. 


Pneumonia  not  a  very 
frequent  complication. 

Sequelae :  chronic  diar- 
rhoea ;  glandular  en- 
largements ;  various 
diseases  of  the  eyeball 
and  eyelids. 


The  contagion  of  smallpox  does  not  always  manifest  itself  by 
an  attack  of  variola.  Sometimes  it  is  modified  by  happening  in 
a  person  who  is  partially  protected  by  vaccination.  This  vario- 
loid disease  is  mild.  It  is  distinguished  from  variola  by  the  pus- 
tules passing  more  quickly  through  all  their  stages,  and,  above 
all,  by  an  absence  of  secondary  fever.  Soon  after  the  eruption, 
within  thirty-six  hours,  the  thermometer  shows  entire  freedom 
from  fever,  and,  unless  serious  complications  happen,  the  heat  of 
the  body  remains  at  nearly  the  normal  temperature. 

Varicella. — A  specific  disorder  very  similar,  to  state  in  these 
words  an  opinion  which  has  been  the  subject  of  many  fierce  dis- 
putes, is  chicken-pox,  or  varicella.  Without  entering  into  the 
controversy,  it  may  be  shown  to  differ,  as  regards  its  symptoms, 


846  MEDICAL    DIAGNOSIS. 

from  smallpox  in  the  leniency  of  the  introductory  fever;  in  the 
eruption  beginning  generally  first  on  the  trunk,  occurring  often 
on  the  second  day,  though  it  may  not  show  itself  until  the  end  of 
the  third,  and  continuing  to  appear  and  disappear  in  crops,  the 
mass  of  the  eruption,  however,  having  become  evident  within 
twenty-four  hours ;  in  the  vesicles  being  surrounded  by  little  or 
no  inflammatory  redness;  in  their  remaining  vesicles,  and  not 
becoming  pustules;  in  their  attaining  their  height  on  the  third 
or  fourth  day  of  the  eruption,  and  then  bursting  and  shrivelling 
without  presenting  depressions  at  their  apices,  and  in  the  crust 
which  falls  off  about  five  days  subsequently  being  followed  by  a 
smooth,  shining,  round,  and  irregular  pit.  Then  the  eruption  is 
rarely  prominent  on  the  face ;  and  the  disease  does  not  protect,  as 
mild  forms  of  smallpox  do,  from  a  subsequent  attack  of  variola. 
Sometimes  the  vesicles  may  be  found,  as  arc  the  pustules  of  small- 
pox, on  the  roof  of  the  mouth  and  at  the  back  of  the  throat. 
But,  notwithstanding  they  may  be  everywhere  very  plentiful,  the 
disorder  is  not  a  grave  one.  Still,  I  have  known  it  in  one  case  to 
terminate  fatally. 

Dengue. — This  is  an  arthritic  fever  with  a  cutaneous  eruption. 
It  has  been  prevalent  in  the  form  of  epidemics  chiefly  in  the 
West  and  East  Indies,  as  well  as  in  Virginia  and  South  Carolina, 
and  other  of  the  Southern  States. 

It  usually  begins  with  pain,  stiffness,  and  swelling  of  some  of 
the  smaller  joints,  or  with  severe  muscular  pains,  aching  in  the 
back,  and  stiffness  of  the  muscles  of  the  neck.  Fever  follows, 
with  suffusion  of  the  eyes,  and  headache ;  but,  as  a  rule,  without 
nausea  and  v<  uniting.  On  the  third  day  the  fever  ceases  altogether, 
or  subsides  markedly,  though  the  muscular  and  arthritic  pains  do 
not  pass  off  entirely.  The  febrile  paroxysm  may  last  somewhat 
longer,  or  only  six  to  twelve  hours.  In  any  case  it  is  apt  to  be 
succeeded  by  an  interval  of  two  to  four  days  free  from  absolute 
suffering,  though  not  from  great  debility  and  some  pain.  Then 
the  pain  returns,  and  with  it  the  fever ;  nausea  and  vomiting  and 
a  thickly-coated  tongue,  too,  are  noticed.  This  new  phase  of  the 
complaint  is  generally  relieved  by  the  appearance  of  an  eruption, 
which  shows  itself  on  the  fifth,  sixth,  or  seventh  day  of  the 
malady,  and,  therefore,  very  much  later  than  the  rash  of  scarla- 
tina, which  it  resembles  often  in  hue  and  aspect.     But  not  in- 


FEVEES.  847 

variably ;  for  it  may  occur  in  patches  and  be  papular,  or  even 
vesicular  or  like  urticaria.  The  eruption  is  attended  with  a  sense 
of  burning  and  of  itching,  and  disappears  after  two  or  three 
days'  duration.*  Then  convalescence  sets  in,  marked  by  consid- 
erable muscular  weakness  and  general  depression,  and  frequently 
with  the  rheumatic  stiiFness  or  soreness  persisting  for  some  time. 
Swellings  of  the  lymphatic  glands  of  the  neck,  axilla,  and  groin 
occur  in  many  cases,  and  may  continue  during  convalescence. 
"  The  cause  of  this  singular  malady — the  breakbone  fever  of 
parts  of  our  country — is  unknown.  It  is  a  harmless  disorder, 
epidemic,  and  contagious.  Such,  at  least,  is  the  opinion  of  Dick- 
son, to  whom  we  owe  one  of  the  best  descriptions  of  the  disease, 
and  from  whose  published  statements,  based  on  epidemics  observed 
in  Charleston,  I  have  chiefly  drawn  this  sketch. 

Erysipelas. — This  is  an  eruptive  fever,  accompanied  by  in- 
flammation of  the  integument  of  some  part  of  the  body,  generally 
of  the  head  and  face.  This  definition,  of  course,  refers  only  to 
such  cases  as  fall  into  the  hands  of  the  physician,  and  to  them 
alone  the  following  remarks  apply. 

The  disease  begins  with  a  chill,  followed  by  a  fever.  Soon  a 
portion  of  the  face  is  noticed  to  be  red  and  hot.  The  redness 
spreads,  a  clearly-defined  edge  marking  its  onward  march ;  and 
generally  it  does  not  stop  until  it  has  occupied  the  whole  of  the 
face  and  a  considerable  portion  of  the  scalp.  The  features  are  then 
so  tumefied  as  to  be  hardly  recognizable.  The  patient  is  very 
restless,  has  high  fever,  and  not  unfrequently  enlargement  of  the 
glands  at  the  angle  of  the  jaw,  and  sore  throat.  By  the  seventh 
or  eighth  day  the  disease  is  over,  and  large  patches  of  cuticle  fall 
from  the  no  longer  swollen  and  disfigured  countenance. 

This  is  simple  erysipelas;  but  we  may  have  to  contend  with 
more  dangerous  forms  and  somewhat  different  symptoms.  Thus, 
the  affection  may  extend — as  is,  in  truth,  always  its  tendency — 
from  the  true  skin  to  the  subcutaneous  areolar  tissue,  and  give 
rise  there  to  collections  of  pus,  which  reveal  their  presence  by 
chills  and  an  obscure  sense  of  fluctuation,  and  keep  up  an  irri- 
tative fever  until  they  are  discharged.     Irrespective  of  this,  the 


*  A  similar  anomalous  eruption  is  described  by  Dickson  in  tbe  Amer.  Journ. 
of  Med.  Sci.,  July,  1871. 


848  MEDICAL    DIAGNOSIS. 

tumefaction,  while  the  complaint  is  at  its  height,  is  much  greater 
in  this  phlegmonous  variety  of  the  malady,  and  there  is  more 
constitutional  disturbance ;  but,  on  the  other  hand,  there  is  not  so 
much  local  irritation,  for  the  morbid  action  travels  less  rapidly, 
and  often  remains  more  circumscribed.  In  some  cases  the  inflam- 
mation extends  to  the  brain,  and,  instead  of  wandering  at  night, 
always  a  very  common  symptom,  we  have  violent  delirium,  soon 
succeeded  by  coma  and  rapid  sinking.  In  other  cases,  again,  and 
they  are  by  far  the  most  frequent,  we  may  find  these  active  cere- 
bral symptoms  and  yet  not  be  able  to  detect,  after  death,  signs  of 
inflammation  of  the  brain  or  its  membranes.  Now  and  then  the 
disorder  passes  to  the  throat,  reaches  the  larynx  and  bronchial 
tubes,  and  places  life  in  imminent  peril  from  oedema  of  the  glottis, 
or  from  a  hazardous  form  of  capillary  bronchitis.  In  some  in- 
stances a  highly  asthenic  state  becomes  developed,  and  the  patient 
dies  exhausted. 

Internal  lesions  happen  not  unfrequently  in  erysipelas.  I  have 
found  the  urine  albuminous  in  the  great  majority  of  instances.* 
Heart-murmurs  are  not  unusual,  and  are  said  to  depend  upon 
endocarditis,  which  is  doubtful.  Friedreich^  speaks  of  swelling  of 
the  spleen  being  of  common  occurrence  both  in  erysipelas  and  in 
diphtheria. 

The  diagnosis  of  erysipelas  is  not  beset  with  difficulties.  Ery- 
thema resembles  it  most  closely ;  but  there  is  this  manifest  differ- 
ence: in  erythema  there  is  scarcely  any  swelling,  not  much  ten- 
dency to  spread,  and  almost  no  constitutional  disturbance.  The 
ordinary  exanthematous  fevers  may,  at  an  early  stage,  be  mistaken 
for  erysipelas.  But  all  of  them,  even  scarlatina,  have  a  longer 
period  of  febrile  invasion  ;  in  all,  too,  although  the  eruption  takes 
its  origin  at  one  spot,  and  generally  on  the  face,  it  is  not  limited 
there.  The  thickly-clustered  blotches  of  commencing  confluent 
smallpox  and  the  swelling  attending  them  give  at  times  to  the  face 
the  look  of  erysipelas.  But  here,  also,  evidences  can  be  found  of 
a  rash  about  to  appear  all  over  the  body ;  and  should  doubt  still 
exist,  it  is  soon  dispelled  by  the  progress  of  the  eruption.  Some- 
times vesicles  and  even  irregular  pustules  form  in  erysipelas,  and 

*  On  the  Internal  Complications  of  Acute  Erysipelas.     Amer.  Journ.  of 
Med.  Sci.,  Oct.  1877. 

f  Klinische  Vortrage,  No.  75,  1874. 


FEVERS.  849 

occasion  some  misgivings  as  to  whether  the  malady  be  not  a 
chronic  disease  of  the  skin,  such  as  eczema,  pemphigus,  or  impe- 
tigo ;  but  these  affections  lack  the  constitutional  symptoms  and 
the  history  of  a  recent  acute  disease,  and  in  reality  the  likeness 
is  not  a  very  striking  one,  if  the  inflamed  surface  be  carefully 
examined. 

Erysipelas  may  break  out  in  one  part  of  the  body  after  an- 
other, and  the  disease  be  thus  kept  up  for  a  long  period.  This 
erysipelas  migrans  is  a  serious  malady.  The  erysipelatous  affec- 
tion runs  its  course  more  rapidly  and  more  completely  in  one  part 
than  in  another,  and  this  according  to  a  general  law  it  obeys.* 

Erysipelas  may  be  confounded  with  mumps.  This  does  not 
seem  at  first  sight  likely ;  but  I  have  known  the  error  to  be  com- 
mitted. It  was  mainly  caused  by  too  much  stress  being  laid  on 
the  redness  which  is  frequently  found  beneath  one  or  both  ears  in 
parotitis,  but  which,  unlike  erysipelas,  is  attended  with  much  pain 
on  moving  the  jaw,  and  with  decided  glandular  tumefaction.  The 
redness,  moreover,  shows  no  tendency  to  spread,  and  rarely  con- 
tinues for  the  four  or  five  days  during  which  mumps  lasts.  In 
very  young  children,  however,  there  may  be  some  difficulty  in 
diagnosis.  I  have  seen  the  glands  at  the  angle  of  the  jaw  much 
swollen  for  one  or  two  days  prior  to  the  slight  discoloration  over 
them  taking  on  a  deeper  blush,  and  then  spreading  rapidly  as 
marked  erysipelas  over  the  whole  face  and  part  of  the  scalp,  reach- 
ing the  other  jaw,  where  subsequently  the  glands  began  to  swell. 
In  such  cases  great  weight  must;  be  attached  to  the  history  of 
the  case,  to  determine  which  disorder  was  primary,  and  whether 
the  glandular  complaint  was  or  was  not  the  complication.  If 
the  contagion  of  mumps  can  be  traced,  the  matter  is  easily  settled. 

A  fever  with  a  distinct  pharyngitis  as  a  local  manifestation,  the 
so-called  pharyngeal  fever,  is  probably  an  epidemic  erysipelatous 
fever  of  light  type.  It  has  been  particularly  described  by  Austin 
Flint,  Rochester,  f  and  Harvey  E.  Brown.!  The  latter  noticed 
it  among  the  troops  stationed  at  Long  Island  Sound  in  1866. 
The  fever  lasts  from  three  to  six  days,  and,  besides  the  marked 


*  Traced  by  Pfleger  in  70  cases  ;  quoted  in  Schmidt's  Jahrb.,  No.  7,  1873. 
f  Buffalo  Medical  Journal,  1857. 
J  Flint's  Principles  and  Practice  of  Medicine. 

54 


850  MEDICAL    DIAGNOSIS. 

pharyngitis,  is  ordinarily  attended  with  swelling  of  the  lym- 
phatic glands  of  the  neck,  accompanied  by  pain.  The  disease 
shows  a  certain,  not  a  large,  proportion  of  cases  with  erysipelas 
of  the  face,  and  is  thought  to  be  a  mild  form  of  the  erysipelatous 
fever  known  popularly  as  the  "  black  tongue,"  which  prevailed  in 
this  country  from  1841  to  1846,  and  in  about  one-sixth  of  the 
cases  of  which  erysipelas  happened.  In  conjunction  with  this 
epidemic  pharyngitis  also  occurred,  and  puerperal  peritonitis  was 
very  common.* 

*  Flint's  Principles  and  Practice  of  Medicine. 


CHAPTER   XII. 

DISEASES   OF   THE   SKIN.    ' 

To  facilitate  the  discrimination  of  diseases  of  the  skin,  they 
have  been  grouped  into  classes.  These  have  been  arranged  by 
some  authors  in  accordance  with  the  obvious  characters  of  the 
eruption,  by  others  in  accordance  with  its  presupposed  cause  and 
attending  structural  alteration.  The  former  classification  is  that 
of  Willan  and  Bateman,  and,  with  such  modifications  as  the 
knowledge  of  the  day  has  necessitated,  is  still  much  followed. 

Another  system  of  classification  takes  for  its  basis  the  ana- 
tomical seat  and  arrangement  of  the  cutaneous  malady :  it  is 
that  of  Hebra.  As  developed  by  him,  it  is,  however,  not  a 
purely  anatomical,  but  a  mixed  system.  All  diseases  of  the 
skin  are  arranged  in  twelve  classes :  Hypersemise ;  Ansemise ; 
Morbid  secretion  of  the  cutaneous  glands ;  Exudations ;  Hemor- 
rhages; Hypertrophies;  Atrophies;  Neoplasms;  Pseudoplasms ; 
Ulcers ;  Nervous  affections ;  Parasites.  The  fourth  class  is 
the  most  comprehensive,  and  is  divided  into  an  acute  and  a 
chronic;  the  acute  being  subdivided  into  a  contagious  class, — 
the  exanthemata, — and  a  non-contagious, — erythemata,  der- 
matitis, phlyctsenoses.  The  chronic  exudations  are  the  squamous 
affections, — psoriasis,  lichen,  pityriasis  rubra;  the  pruriginous 
affections, — eczema,  scabies,  prurigo ;  the  acniform  affections, — 
acne,  sycosis ;  the  pustular  affections, — impetigo,  ecthyma  ;  and 
the  bullous  affections, — pemphigus. 

Whatever  classification  we  adopt,  when  a  disease  of  the  skin 
is  presented  for  examination  we  generally  first  endeavor  to  ascer- 
tain the  group  it  belongs  to ;  for  instance,  is  it  vesicular,  pustular, 
or  erythematous  ?  Having  determined  this,  we  next  fix  which 
one  of  the  group  it  is ;  and  then  take  note  of  its  precise  seat  and 
its  pathological  causation.  When  this  has  been  accomplished,  we 
inquire  into  the  history  of  the  affection  and  its  duration,  whether 
acute  or  chronic;  take  into  account  the  presence  or  absence  of 

851 


850  MEDICAL    DIAGNOSIS. 

pharyngitis,  is  ordinarily  attended  with  swelling  of  the  lym- 
phatic glands  of  the  neck,  accompanied  by  pain.  The  disease 
shows  a  certain,  not  a  large,  proportion  of  cases  with  erysipelas 
of  the  face,  and  is  thought  to  be  a  mild  form  of  the  erysipelatous 
fever  known  popularly  as  the  "  black  tongue,"  which  prevailed  in 
this  country  from  1841  to  1846,  and  in  about  one-sixth  of  the 
cases  of  which  erysipelas  happened.  In  conjunction  with  this 
epidemic  pharyngitis  also  occurred,  and  puerperal  peritonitis  was 
very  common.* 

*  Flint's  Principles  and  Practice  of  Medicine. 


CHAPTER   XII. 

DISEASES   OF   THE   SKIN.    ' 

To  facilitate  the  discrimination  of  diseases  of  the  skin,  they 
have  been  grouped  into  classes.  These  have  been  arranged  by 
some  authors  in  accordance  with  the  obvious  characters  of  the 
eruption,  by  others  in  accordance  with  its  presupposed  cause  and 
attending  structural  alteration.  The  former  classification  is  that 
of  Willan  and  Bateman,  and,  with  such  modifications  as  the 
knowledge  of  the  day  has  necessitated,  is  still  much  followed. 

Another  system  of  classification  takes  for  its  basis  the  ana- 
tomical seat  and  arrangement  of  the  cutaneous  malady :  it  is 
that  of  Hebra.  As  developed  by  him,  it  is,  however,  not  a 
purely  anatomical,  but  a  mixed  system.  All  diseases  of  the 
skin  are  arranged  in  twelve  classes :  Hypersemise ;  Ansemise ; 
Morbid  secretion  of  the  cutaneous  glands ;  Exudations ;  Hemor- 
rhages ;  Hypertrophies ;  Atrophies ;  Neoplasms ;  Pseudoplasms ; 
Ulcers ;  Nervous  affections ;  Parasites.  The  fourth  claas  is 
the  most  comprehensive,  and  is  divided  into  an  acute  and  a 
chronic;  the  acute  being  subdivided  into  a  contagious  class, — 
the  exanthemata, — and  a  non-contagious, — erythemata,  der- 
matitis, phlycteenoses.  The  chronic  exudations  are  the  squamous 
affections, — psoriasis,  lichen,  pityriasis  rubra;  the  pruriginous 
affections, — eczema,  scabies,  prurigo ;  the  acniform  affections, — 
acne,  sycosis ;  the  pustular  affections, — impetigo,  ecthyma ;  and 
the  bullous  affections, — pemphigus. 

Whatever  classification  we  adopt,  when  a  disease  of  the  skin 
is  presented  for  examination  we  generally  first  endeavor  to  ascer- 
tain the  group  it  belongs  to ;  for  instance,  is  it  vesicular,  pustular, 
or  erythematous  ?  Having  determined  this,  we  next  fix  which 
one  of  the  group  it  is ;  and  then  take  note  of  its  precise  seat  and 
its  pathological  causation.  When  this  has  been  accomplished,  we 
inquire  into  the  history  of  the  affection  and  its  duration,  whether 
acute  or  chronic ;  take  into  account  the  presence  or  absence  of 

851 


852 


MEDICAL    DIAGNOSIS. 


fever,  and  the  general  condition  of  the  patient;  search  for  the 
evidences  of  a  cachexia  or  of  some  visceral  disturbance, — a  study 
the  importance  of  which  is  as  great  as  that  of  the  recognition  of 
the  cutaneous  malady ;  and  trace,  as  far  as  possible,  the  cause  of 
the  disorder.  Having  done  all  this,  we  have  a  groundwork  upon 
which  to  institute  a  suitable  treatment. 

Here  is  a  table  in  which  cutaneous  affections,  omitting  some 
of  the  less  important  ones,  are  grouped,  for  the  most  part  accord- 
ing to  their  most  obvious  features,  as  well  as  according  to  their 
pathological  bearings : 


Diseases  of  the  Skin. 


Erythematous  Diseases. 


f  Erythema. 
-J   Eoseola.  . 
I    Urticaria. 


Inflammatory.  -J 


Squamous  Diseases. 


Papular  Diseases /  Lichen. 

I  Prurigo. 

Vesicular  Diseases J  Eczema. 

I  Herpes. 

Bullous  Diseases f  Pemphigus. 

I  Hydroa. 

f  Acne. 

Pustular  Diseases I   ImPetiS°- 

I    Ecthyma. 

i    Kupia. 
Lepra. 
Psoriasis. 
Pityriasis. 
Ichthyosis. 
Melasma. 
Ephelides. 
Macule;  Pigmentary  Changes J  Vitiligo. 

Chloasmata. 
Nsevi. 

f  Cancer. 

New  Growths •   Lupus. 

1   Elephantiasis  Grsecorum, 

I      etc. 

C  Elephantiasis  Arabum. 

Hypertrophies  of  Special  Textures !  bclerema- 

j  Keloid. 

[  Warts,  Corns,  etc. 

Atrophies /  As  of  the  Hair;  the  Nails. 

*-  Senile  Atrophy. 


DISEASES    OF   THE   SKIN. 


853 


Diseases  or  the  Skin — Continued. 


Parasitic  Diseases. 


Altered  Gland-Secretion 


of  Sebaceous  Glands 


of  Sweat-Glands 


Nervous  Affections. 


Scabies. 

Phtbeiriasis. 

Pavus. 

Mentagra. 

Tinea  circinata. 

Tinea  tonsurans. 

Tinea  decalvans. 

Pityriasis  versicolor,  etc. 

r  Seborrboea. 

\  Molluscum. 

C  Hyperidrosis. 

j   Anidrosis. 

]   Sudamina,  etc. 
Hyperesthesia. 
Ansestbesia. 
Pruritus. 
Neuroma. 


Constitutional  Skin  Affections i     ^P 

I  Scrofuloderma^ 


a,  etc. 


Most  diseases  of  the  skin  are  again  subdivided  into  several 
varieties,  based,  for  the  most  part,  on  their  duration,  situation, 
form,  feel,  and  color.  Thus,  we  have  constantly  recurring  the 
terms  fugax,  inveterata,  capitis,  facialis,  palmaris ;  guttata,  when 
like  a  drop  on  the  skin;  nummularis,  when  like  a  coin;  larvalis, 
like  a  mask,  etc.;  the  qualifying  words,  lseve,  induratum;  and 
the  adjectives  of  color,  nigrum,  rubrum,  versicolor.  But  these 
divisions  are  all  of  secondary  importance;  and  I  shall  not,  in 
this  outline,  pay  much  regard  to  them.  Premising  this  statement, 
let  us  briefly  examine  the  characteristics  of  the  various  cutaneous 
affections  of  more  common  form,  beginning  with  those  that  are  of 
inflammatory  origin. 

Erythematous  Diseases. — This  group,  regarded,  too,  as 

rashes,  is  often  made  to  include  morbilli,  rubeola,  scarlatina,  and 
erysipelas ;  but  these  belong  rather  to  fevers  than  to  diseases  of 
the  skin,  and  have  been  described  already.  There  are  only  three 
affections  which,  strictly  speaking,  come  under  this  division  of 
cutaneous  complaints :  erythema,  roseola,  and  urticaria.  In  all 
of  these  the  skin  is  more  or  less  red,  and  its  surface  unbroken ; 
the  hypersemia  affects  chiefly  the  papillary  layer. 

Erythema  is  characterized  by  a  uniform  and  continuous  redness 


854  MEDICAL    DIAGNOSIS. 

of  the  skin,  occurring  in  irregular  patches  of  some  size,  and  at- 
tended with  some  itching  or  burning,  and  with  but  slight  swelling, 
if  with  any,  and  disappearing  without  desquamation.  The  erup- 
tion is  chiefly  found  on  the  back  of  the  bauds,  the  forearms,  the 
legs,  and  the  face  and  neck;  but  rarely  on  the  trunk.  There  is 
little  or  no  itching.  The  affection  may  be  due  to  the  action  of 
heat  or  cold,  or  of  irritants ;  it  may  or  may  not  be  associated  with 
disturbance  of  the  general  health  ;  usually  it  is  acute,  and  con- 
nected with  some  visceral  disorder.  There  is  only  one  variety  apt 
to  be  combined  with  decided  constitutional  or  febrile  symptoms, — 
the  hard,  painful  protuberances  most  commonly  seen  on  the  legs, 
and  constituting  the  so-called  "  erythema  nodosum."  This  form 
of  the  complaint,  in  which  there  is  a  serous  effusion  into  or  under 
the  skin,  is  chiefly  observed  in  those  of  rheumatic  diathesis. 

A  chronic  form  of  erythema  results  from  pressure,  or  the  rub- 
bing together  of  folds  of  skin,  as  the  erythema  intertrigo  ;  a  slight 
discharge  may  coat  the  rubbed  surface. 

Roseola  consists  in  circumscribed  spots  of  a  rose-red  color  and 
of  a  more  or  less  circular  form.  The  spots  are  smaller  than  those 
of  erythema.  There  is  slight  fever,  and  at  times  redness  of  the 
fauces.  The  affection  often  exists  in  connection  with  a  derange- 
ment of  the  stomach,  or  with  rheumatism,  is  frequent  in  summer 
and  in  autumn,  is  generally  acute,  and  bears  a  certain  resemblance 
to  scarlatina  and  to  measles ;  but  it  is  not  contagious,  its  constitu- 
tional symptoms  are  much  milder,  the  rash  is  rosy,  not  crescentic, 
or  present  over  the  whole  body,  and  we  find  neither  the  marked 
sore  throat  of  scarlet  fever  nor  the  catarrh  of  measles. 

Urticaria,  or  nettle-rash,  gives  rise  to  prominent  and  perfectly 
smooth  patches,  the  color  of  which  is  either  redder  or  whiter  than 
the  surrounding  skin,  or  the  white  wheals  are  surrounded  by  a 
red  border.  The  eruption  is  fugitive  and  capricious,  is  attended 
with  more  itching  and  tingling  than  the  other  exanthemata,  and 
is  much  more  evanescent,  generally  disappearing  in  two  days  at 
furthest.  It  may,  however,  exist  in  a  chronic  form,  the  wheals 
coming  out  in  constant  succession. 

The  cause  of  urticaria  is  irritation  of  the  gastro-intestinal,  pul- 
monary, or  urinary  mucous  membrane.  Certain  kinds  of  fish, 
especially  shell-fish,  are  particularly  prone  to  produce  it ;  so  may 
strawberries.     At  times  it  is  produced  by  menstrual  disorders  or 


DISEASES    OF   THE   SKIN.  855 

sudden  mental  emotion,  or  by  the  excessive  use  of  mineral  waters. 
It  may  be  secondary  to  the  itch  or  to  phtheiriasis.  Urticaria  is 
thought  generally  to  be  an  exudative  disease  of  the  skin ;  but 
there  are  those  who  believe  that  it  is  only  a  spasmodic  contraction 
of  the  muscular  tissue  of  the  cutis;*  and  it  seems  to  me  most 
probable  that  it  is  wholly  a  reflex  phenomenon,  caused  chiefly  by 
reflected  irritation  to  the  cutaneous  vaso-motor  nerves. 

Urticaria  resembles  erythema  nodosum ;  but  there  is  no  itching 
in  the  latter  affection,  it  is  chiefly  found  in  the  lower  limbs,  and 
the  swellings  change  like  bruises. 

Papular  Diseases. — A  papule,  or  pimple,  is  a  small  elevation 
of  the  cuticle  with  an  inflamed  base;  it  does  not  contain  fluid,  and 
usually  terminates  in  desquamation.  It  often  results  from  a  small 
amount  of  lymph  or  newly-formed  growth  in  the  derm  itself. 

Lichen  furnishes  the  best-marked  example  of  a  papular  erup- 
tion. It  consists  of  minute  conical  papulse,  generally  of  reddish 
color,  and  occurring  in  clusters.  It  is  most  frequently  encoun- 
tered in  the  summer  months  and  in  adults,  and  often  in  persons 
of  good  health  but  who  have  been  exposed  to  much  fatigue  or 
anxiety.  Sometimes  it  is  evidently  connected  with  disordered 
digestion.  It  is  very  commonly  chronic.  When  it  assumes  a 
circular  form,  it  is  designated  as  a  species  of  ringworm.  The 
lichen  of  young  children  and  of  infants,  in  which  the  papulae 
and  sweat-glands  are  highly  congested,  and  which  is  chiefly  found 
on  the  face  and  arms,  is  called  "  strophulus."  There  is  often  a 
mixture  of  papulee  with  an  eczematous  eruption;  indeed,  there  is 
a  close  relationship  between  the  two  disorders.  Prickly  heat,  or 
lichen  tropicus,  frequently  exhibits  also  sudamina. 

In  the  lichen  ruber  of  Hebra  the  red  papules  are  the  size  of  the 
head  of  a  pin ;  they  spread  by  peripheral  growth,  are  flat,  ir- 
regular, have  a  glazed  look,  and  have  very  slight  scales ;  there  is 
considerable  itching.  The  disease  resembles  psoriasis,  but  at  the 
edge  of  the  patch  are  the  characteristic  papules. 

In  the  lichen  scrofulosorum  the  eruption  consists  of  little  pale 
papules,  which  are  chiefly  found  on  the  trunk.  There  is  no 
itching ;  but  we  find  marked  signs  of  scrofula. 

Prurigo  is  a  papular  affection  of  the  skin  attended  with  ex- 

*  Gull,  Guy's  Hospital  Beports,  3d  Series,  vol.  v. 


856  MEDICAL    DIAGNOSIS. 

cessive  itching.  The  pimples  are  generally  torn  by  the  finger- 
nails, and  are  surmounted  by  black  scabs.  They  are  not  red,  as 
those  of  lichen  usually  are,  and  are,  as  a  rule,  larger,  and  accom- 
panied by  much  more  pruritus  and  by  thickening  of  the  skin. 
The  affection,  which  is  rare,  may  or  may  not  be  attended  with 
constitutional  symptoms.  It  is  very  distressing  and  obstinate, 
especially  when  happening  in  old  persons.  It  generally  affects 
particularly  the  arms  and  legs,  very  rarely  the  face  and  neck. 
The  skin  of  the  anterior  and  outer  part  of  the  leg  is  most  changed; 
that  over  the  flexors  in  the  forearm  is  always  healthy.  The  dis- 
tressing disorder  may  be  purely  local,  occurring  around  the  anus, 
or  on  the  scrotum  and  the  root  of  the  penis,  or  on  the  pudenda. 
Some  of  these  cases,  however,  though  called  prurigo,  present  no 
papulae,  and  the  disorder  is  due  to  perverted  sensibility  of  the 
cutaneous  nerves  alone ;  and  is  really  a  pruritus. 

Prurigo  can  often  be  traced  to  want  of  personal  cleanliness. 
But  a  good  many  supposed  instances  of  the  malady  are  not  really 
prurigo,  but  phtheiriasis,  due  to  the  irritation  of  body  lice,  that 
produce  papules,  whose  apices  are  scratched  off  and  show  little 
points  of  dried  blood.  True  prurigo  is  frequently  found  to  be 
connected  with  deterioration  of  the  health,  and  is  essentially  an 
affection  of  the  nerves.  It  may  last  a  lifetime,  beginning  in 
childhood.  Its  local  forms  are  associated  with  irritation  of  the 
bladder,  rectum,  or  uterus. 

Vesicular  Diseases. — These  are  characterized  by  an  effusion 
of  a  clear  or  a  sero-purulent  fluid  beneath  the  epidermis,  which  is 
generally  raised  in  small  elevations.  To  the  class  of  vesicular 
diseases  belong  especially  eczema  and  herpes. 

Eczema  consists  of  minute  vesicles  collected  together  in  irregular 
patches.  The  vesicles  are  often  confluent,  and  it  then  appears  as 
if  the  whole  surface  were  secreting  fluid.  This  may  harden,  from 
exposure  to  the  air,  into  scabs  of  various  thickness  and  color.  The 
skin  itself  is  often  of  a  vividly  red  hue ;  indeed,  it  is  inflamed,  and 
a  new  cell-growth  takes  place  both  in  the  rete  mucosum  and  in  the 
papillary  layer  of  the  derm.  It  is  there  that  the  effusion  of  serum 
begins.  In  chronic  cases  the  inflammatory  infiltration  extends 
deeper  into  the  skin. 

Eczema  may  affect  the  whole  body,  but  is  ordinarily  limited  to 
some  portion  of  it.     It  is  acute  or  chronic.     The  former  is  gen- 


DISEASES   OF   THE   SKIX.  857 

erally  seen  as  the  effect  of  local  irritants,  and  may  be  met  with  in 
young  and  healthy  persons.  Chronic  eczema  is  more  common,  is 
often  the  consequence  of  constitutional  disturbance,  and  is  fre- 
quently found  to  be  associated  with  some  disorder  of  the  digestive 
system.  It  has  as  a  frequent  seat  the  flexor  surfaces  of  the  limbs. 
Dentition  and  unhealthy  milk  are  common  sources  of  the  affection 
in  very  young  children.  In  them  the  disease  is  extremely  apt  to 
attack  the  scalp  and  face,  forming  the  complaint  often  described 
as  "crusta  lactea;"  or,  if  the  secretion  be  partly  purulent,  or 
early  become  so,  and  dry  into  large,  dark  scabs,  the  malady  is 
designated  as  eczema  imjpetiginodes.  This  is  most  common  in 
scrofulous  subjects. 

In  some  of  the  forms  of  eczema,  especially  in  its  chronic  varie- 
ties, the  vesicles  supposed  to  characterize  the  disorder  can  often 
not  be  found.  This  and  other  reasons  have  caused  several  recent 
dermatologists,  especially  Hebra*  and  Anderson, f  to  deny  that 
eczema  need  be  vesicular  at  all.  Infiltration  of  the  skin,  exuda- 
tion on  its  surface,  the  formation  of  crusts,  and  itching,  are  held 
to  be  its  distinctive  signs,  while  the  eruption  is  at  its  height ;  but  the 
eruption  may  consist  of  clusters  of  papules,  vesicles*  or  pustules,  or 
there  may  not  be  a  vestige  of  any  of  these,  the  skin  being  red  and 
smooth  and  secreting  a  sticky  discharge,  or  covered  with  green  or 
gummy  crusts,  or  fissured  with  deep  cracks.  A  scaly  form  of 
eczema,  eczema  squamosum,  is  apt  to  be  confined  to  the  hands  and 
feet.  In  all  the  forms  of  eczema,  as  Hebra  insists  upon,  we  have 
severe  itching.  This  itching  is  especially  violent  in  the  form  with 
the  deep-red  and  weeping  surface,  named  eczema  rubrum.  It  is 
in  this  form  that  we  have  the  signs  of  local  inflammation  very 
marked,  and  we  often  find  it  in  gouty  or  in  dyspeptic  subjects. 
It  has  a  predilection  for  the  flexures  of  the  joints. 

Eczema,  particularly  when  it  affects  the  scalp  and  face,  must 
not  be  confounded  with  the  morbid  secretion  from  the  sebaceous 
follicles  giving  rise  to  soft  crusts.  Seborrhoea  by  preference 
attacks  the  parts  mentioned;  but  its  crusts,  as  Hardy  has  shown, 
are  unlike  those  of  eczema  in  the  readiness  with  which  they  are 
detached,  and  susceptible  of  being  moulded  between  the  fingers. 


Hautkrankheiten  ;  or  translation  by  Sydenham  Society. 
A  Practical  Treatise  on  Eczema,  London,  1863. 


858  MEDICAL    DIAGNOSIS. 

The  surface  beneath  the  crusts,  too,  Is  dissimilar.     It  has  an  oily, 
glistening  look  ;  there  is  no  discharge. 

Eczema  may  be  confounded  with  pityriasis  rubra.  But  this  is 
apt  speedily  to  involve  the  whole  surface  of  the  body,  and  is  not 
accompanied  by  discharge. 

Herpes,  like  eczema,  is  classed  as  a  vesicular  affection,  although 
by  some  it  is  placed  in  the  bullous  group,  and  differs  from  the 
obviously  vesicular  form  of  eczema  by  the  larger  size  of  the  vesi- 
cles. These  are  generally  of  a  globular  form,  and  are  symmetri- 
cally arranged  in  clusters  upon  an  inflamed  patch  of  skin.  Each 
vesicle  is  distinct,  and  remains  so  throughout  its  course.  It  lasts 
about  eight  to  twelve  days,  and  often  terminates  by  the  formation 
of  a  thin  incrustation.  The  eruption  is  attended  with  burning, 
and  in  the  acute  variety  with  some  fever. 

Herpes  has  seldom  a  longer  duration  than  three  weeks  ;  though  it 
may  be  a  chronic  disease.  It  happens  usually  in  persons  of  delicate 
skin ;  is  generally  very  local,  having  its  seat  on  the  lips,  eyelids,  pre- 
puce, or  pudenda;  and  is  almost  invariably  associated  with  an  in- 
ternal disease,  especially  with  irritation  of  some  portion  of  the  gastro- 
pulmonary  mucous  membrane.  Herpes  labialis  often  appears  at , 
the  decline  or  termination  of  fevers;  sometimes  at  the  height  of 
acute  maladies,  as  in  pneumonia.  The  most  distressing  form  of 
herpes  is  that  extending  around  one-half  of  the  trunk, — herpes 
zoster,  an  acute  disorder,  which  may  show  itself  over  the  course 
of  any  of  the  superficial  nerves.  Indeed,  herpetic  or  bullous 
eruptions  often  happen  over  the  course  of  the  nerves,  and  a  nerve- 
lesion  the  result  of  disease  or  of  an  injury  will  produce  them 
over  the  disordered  nerve.  In  herpes  zoster  around  the  chest,  the 
severe  pain  preceding  the  eruption  is  often  mistaken  for  pleurisy. 

Herpes  and  eczema  may  both  be  confounded  with  scabies,  which, 
like  them,  occasions  a  vesicular  eruption  which  is  apt  to  be  found 
on  the  inner  surface  of  the  limbs  and  flexures  of  the  joints.  The 
distinction  consists  in  the  more  severe  itching;  in  the  small  coni- 
cal vesicles,  torn,  as  they  so  usually  are,  by  scratching;  and  in 
the  presence  of  the  acarus,  which  may  be  removed  from  its  burrow 
with  the  point  of  a  needle  or  any  sharp  instrument. 

Bullous  Diseases. — Bulla?  differ  from  vesicles  only  in  their 
size.  The  typical  bullous  disease  is  pemphigus.  This  affection  is 
not  often  met  with.     It  appears  in  very  large  vesicles  or  bullae, 


DISEASES    OF   THE   SKIN.  859 

surrounded  by  a  slight  zone  of  erythematous  redness.  The  blebs 
occur  in  crops,  and  look  like  small  blisters  filled  with  serum.  They 
are  not  found  on  the  scalp ;  where  there  are  but  few  bulla?  we 
generally  find  them  on  the  ankle,  or  on  the  hand.  The  disorder 
may  be  acute  or  chronic.  It  is  ordinarily  chronic,  and  happens 
in  persons  of  enfeebled  constitution.  Pemphigus  may  be  pro- 
duced by  the  administration  of  iodide  of  potassium,*  or  by  syphi- 
lis. Syphilitic  pemphigus  is  mainly  met  with  on  the  soles  of  the 
feet  and  the  palms  of  the  hands  of  newly-born  syphilitic  children. 
There  is  a  form  of  extensive  pemphigus  with  flaky  incrustations 
like  eczema, — pemphigus  foliaceus.  But  we  can  still  find  bulla?, 
and  there  is  great  attending  prostration. 

Hydroa. — This  is  a  disease  like  herpes,  only  occurring  in  a  more 
diffused  manner  and  presenting  larger  vesicles ;  in  this  respect  it 
stands  midway  between  herpes  and  pemphigus.  It  is  a  chronic 
condition,  lasting  usually  five  to  eight  months,  and  there  are  in 
this  period  usually  many  acute  or  subacute  outbreaks,  in  which 
the  large  vesicles  form  and  then  dry  away.  These  attacks  are  at- 
tended Avith  considerable  itching.  The  base  of  the  vesicle  is  red, 
and  it  forms  out  of  a  red  papule.  The  disorder  chiefly  happens 
in  persons  of  depressed  nervous  system  or  of  gouty  taint.  It  has 
been  confounded  with  the  eruption  of  bulla?  from  iodide  of  potas- 
sium, but  these  are  much  larger,  are  more  persistent,  and  leave  a 
marked  scar. 

Pustular  Diseases. — These  are  marked  by  circumscribed 
elevations  of  the  cuticle  which  contain  pus.  Acne,  impetigo,  and 
ecthyma  belong  to  the  group.  Rupia,  too,  although  often  classed 
among  the  bullous  disorders,  appertains  more  strictly  to  the  pus- 
tular, unless  we  prefer  to  class  it  with  the  syphilides. 

Acne  is  an  eruption  of  hard,  isolated,  red  elevations,  due  to 
chronic  inflammation  of  the  sebaceous  follicles  and  the  areolar 
tissue  around  them  ;  plugs  of  sebum  are  retained  in  the  ducts.  At 
the  apices  of  many  of  these  elevations  pus  forms,  which  is  dis- 
charged, leaving  a  hardened  base,  which  only  gradually  disappears. 
Acne  is  generally  seen  on  the  face  and  shoulders.  Men  of  seden- 
tary occupations  and  drunkards  are  very  liable  to  it.  In  women 
it  is  frequently  associated  with  uterine  disturbances  ;  in  men,  with 

*  Bumstead,  Amer.  Journ.  of  Med.  Sci.,  July,  1872. 


860  MEDICAL    DIAGNOSIS. 

some  genitourinary  disorder.  An  acne  eruption  also  follows  the 
use  of  the  bromides  and  iodides  internally,  and  the  local  use  of 
tar.  In  acne  rosacea  lymph  is  generally  effused  into  the  papillary 
layer  of  the  skin,  and  some  acne  pustules  are  mixed  with  the  red- 
dened, altered  skin. 

Impetigo  presents  small  pustules  occurring  in  successive  crops 
and  arranged  in  clusters.  The  pustules  are  but  little  raised  above 
the  surface,  soon  break,  and  a  thick,  yellowish  or  greenish  crust 
is  developed.  When  the  disorder  attacks  the  scalp  and  face, 
especially  in  infants  and  children,  it  gives  rise  to  very  extensive 
incrustations,  and  constitutes,  particularly  if  conjoined  with  eczema, 
the  affection  designated  as  "porrigo  larvalis."  By  some  impetigo 
is  looked  upon  simply  as  a  pustular  eczema.  There  is  a  con- 
tagious form  of  it,  described  first  by  Tilbury  Fox,  which  occurs 
acutely,  is  epidemic,  preceded  by  fever,  and  unattended  with  pain 
or  itching. 

Ecthyma  differs  from  impetigo  by  the  larger  size  and  greater 
prominence  of  the  pustules  and  their  inflamed  base.  When  the 
crust  that  forms  on  each  pustule  falls,  a  highly-congested  surface 
or  a  superficial  ulceration  is  seen,  which  leaves  a  cicatrix.  The 
disorder  is  painful  and  connected  with  a  cachectic  state  of  the 
system  ;  irritation  of  the  skin  may  excite  it.  It  bears  a  certain 
resemblance  to  sycosis  ;  but  the  limitation  to  the  hairy  portions  of 
the  face,  the  yellow  color  of  the  pustules,  their  conical  form  and 
smaller  size,  and  the  brown  crusts  they  occasion,  distinguish  this 
malady. 

Rupia  produces  at  first  bullae,  but  soon  very  large  pustules,  that 
desiccate  into  thick,  brownish  crusts,  often  of  conical  shape  or 
resembling  the  shell  of  an  oyster,  and  which,  when  thrown  off, 
expose  ulcerations  of  various  depth  that  are  slow  to  heal,  and  on 
which  fresh  crusts  arise.  The  disease  runs  a  chronic  course.  It 
occurs  especially  on  the  lower  extremities,  is  probably  always 
syphilitic,  and  coexists  with  a  deteriorated  constitution.  It  is 
very  like  ecthyma,  and  can  be  distinguished  only  by  the  history 
of  the  case,  the  evidences  of  syphilitic  taint,  the  persistent  ulcer- 
ations, and  the  prominent,  peculiarly-shaped  crusts. 

Squamous  Diseases. — Here  the  predominant  characteristic 
is  the  formation  of  small,  whitish  patches  of  unhealthy  cuticle 
covering  red  papular  elevations  or  a  deep-red,  somewhat  thickened 


DISEASES   OF   THE   SKIN.  861 

surface ;  the  scales  are  generally  very  freely  thrown  off.  Lepra 
and  psoriasis  are  the  main  disorders  belonging  to  the  group.  Pity- 
riasis is  included  by  many,  while  others  regard  it  as  merely  a 
variety  of  chronic  erythema,  or  of  eczema.  It  differs  from  lepra 
and  psoriasis  by  the  production  of  minute  squamae,  which  are 
constantly  thrown  off  and  reformed,  and  which  are  seated  on  a 
reddened  integument ;  hence  its  chief  variety  is  designated  pityri- 
asis rubra.  It  generally  begins  at  a  special  point,  and  spreads 
over  the  body.  The  skin  is  very  red,  and  not  thickened  except 
in  instances  of  very  long  standing ;  there  is  no  discharge,  as  in 
eczema;  the  scales  are  loosely  adherent  to  the  surface,  at  times 
they  come  off  in  large  flakes.  The  disease  is  most  apparent  on 
the  body  and  the  limbs.  There  is  rarely  marked  itching  or  burn- 
ing; but  the  general  health  deteriorates  in  chronic  cases. 

Lepra  and  psoriasis  may  be  described  together,  since  there  is 
no  real  difference  between  them ;  indeed,  the  term  lepra  is  aban- 
doned by  most  late  writers,  and  psoriasis  embraces  lepra.  In  both 
we  find  patches  of  a  red  hue  raised  above  the  surrounding  integu- 
ment and  covered  by  scales  of  dried  epidermis.  In  lepra  these 
patches  have  a  circular  or  circumscribed  shape,  and  the  scales  are 
large  and  well  defined.  In  psoriasis,  on  the  other  hand,  while 
generally  the  scales  more  completely  cover  the  morbid  portion  of 
skin,  they  are  finer,  and  the  patches  are  large  or  consist  of  very 
small  ones  which  have  coalesced  into  a  single  large  one,  are  not 
of  an  annular  form,  and  not  so  completely  separated  by  healthy 
skin. 

Psoriasis  generally  first  appears  on  the  extensor  surfaces  of  the 
elbow-  and  knee-joints,  and  finally  on  the  face,  where  the  scales 
are  usually  very  small.  As  Robinson,  of  New  York,  has  recently 
proved,  the  morbid  change  begins  in  the  cells  of  the  epidermis. 
There  is  scarcely  any  itching  attending  the  affection. 

Psoriasis  is  often  hereditary ;  in  old  persons  it  is  frequently  of 
gouty  origin.  It  is  a  chronic  affection,  and  extremely  obstinate. 
It  is  liable  to  be  mistaken  for  lichen,  especially  lepra,  the  isolated 
circular  form  of  it.  It  is,  however,  distinguished  by  the  distinct, 
dry,  and  silvery  scales,  and  by  the  smooth,  red,  perhaps  bleeding 
skin,  which  is  at  once  perceived  when  the  scales  are  detached. 
Psoriasis  has  a  predilection  for  the  vicinity  of  the  joints,  especially 
the  elbow-  and  knee-joints.      Sometimes  it  appears  exclusively  on 


862  MEDICAL    DIAGNOSIS. 

the  palm  of  the  hand  ;  and  in  this  form  especially  we  are  apt  to 
find  deep  cracks.  Psoriasis  differs  from  eczema  squamosum  by  the 
latter  having  preceding  vesicles  and  itching. 

Indeed,  psoriasis  is  distinguished  from  all  forms  of  eczema  by 
the  absence  of  fluid  effusion  at  any  time  in  the  history  of  the  case. 
In  scaly  syphilitic  eruption  the  scales  are  comparatively  few  and 
fine,  when  they  are  removed  the  dense  skin  underneath  does  not 
bleed,  and  the  eruption  is  not  likely  to  be  met  with  on  the  elbows 
and  the  knees. 

Ichthyosis,  or  fish-skin,  is  also  a  squamous  disease;  but  it  differs 
from  the  others  of  this  class  in  being  much  more  general,  affect- 
ing as  it  does  often  the  whole  integument,  and  in  the  absence  of 
reddening  or  any  signs  of  inflammation  of  the  surface.  It  is  on 
that  account  classed  by  some  as  a  mere  hypertrophy  of  the  cuticle. 
The  skin  is  dry,  dirty,  and  rough,  and  covered  with  thickened  and 
exfoliating  cuticle  and  with  sebum  ;  there  may  also  be  fissures 
and  cracks.  Ichthyosis  is  almost  always  of  congenital  origin;  it 
affects  the  whole  body,  though  the  face  but  very  slightly. 

Maculae. — These  include  stains  on  the  skin  which  are  due  to 
chemical  substances,  such  as  nitrate  of  silver,  or  blood-spots,  as 
in  purpura,  or  spots  in  consequence  of  parasitic  formations,  as  in 
tinea  versicolor.  But  their  chief  cause  is  increased  pigmentation; 
and  it  is  this  cause  that  we  shall  look  at  more  particularly. 

First,  lentigo  may  be  mentioned.  This  consists  of  the  little 
yellow  or  yellowish-brown  spots  so  often  met  with  on  the  face  and 
on  the  arms  in  children  under  eight  years  of  age,  and  which,  if 
they  have  persisted,  disappear  in  middle  life.  Similar  spots  are 
ephelides,  or  freckles,  which,  though  aggravated  by  exposure  to  the 
sun,  may  exist  all  the  year  round.  Melasma  is  a  very  dark  pig- 
mentation, which,  although  it  has  been  met  with  in  an  epidemic 
form,  is  commonly  seen  in  connection  with  Addison's  disease. 

Chloasma  consists  of  a  brownish  or  yellowish-brown  pigmen- 
tation, giving  rise  to  the  so-called  liver  spots.  They  are  smooth 
and  well-defined  maculae  without  scales,  and  may  result  from  any 
local  irritation  or  from  exposure  to  the  sun.  They  may  also 
happen  in  cases  of  faulty  digestion  with  torpor  of  the  liver,  in 
uterine  disorders,  and  in  the  pregnant  state.  Tinea  versicolor 
is  often  embraced  under  the  same  name,  and  is  constantly  con- 
founded with  these  so-called  liver  spots.     But  it  is  much  more 


DISEASES   OF    THE   SKIN.  863 

itchy,  is  slightly  raised,  and  in  the  scales  we  scrape  off  are  found 
the  characteristic  fungus. 

New  Growths. — These  are  hard,  indolent,  and  often  perma- 
nent tumors  of  the  skin,  which  in  their  main  forms  consist  of 
granulation  tissue.  Lupus  and  elephantiasis  of  the  Greeks  mainly 
illustrate  this  group. 

In  lupus  a  tissue  is  formed  like  granulation  tissue,  and  the  new 
growth  mostly  takes  place  in  the  form  of  tubercles.  These  may 
or  may  not  ulcerate.  They  are  of  a  dull-red  color,  elevated  above 
the  surface,  have  a  well-defined  outline,  spread  outward  into 
normal  textures,  and,  if  they  ulcerate,  destroy  the  tissues  in  which 
they  are  situated.  The  ulcers  also  spread,  and  may  occasion  much 
devastation.  When  they  heal,  they  leave  a  strongly-marked 
whitish  cicatrix  and  an  unhealthy-looking  skin.  The  disorder 
occurs  in  syphilitic  or  in  scrofulous  persons, — generally  in  the 
latter, — is  attended  with  some  pain  and  itching,  and  pursues  a  very 
slow  course.  The  nose  and  cheek  are  the  favorite  sites.  There 
is  a  form  of  lupus  occurring  only  in  strumous  subjects,  and  char- 
acterized by  warty  formations.  This  lupus  verrucosus  is  without 
pain  or  itching,  but  cicatrices  form,  though  there  has  been  no 
previous  ulceration.*  In  lupus  erythematodes  the  disease  is  super- 
ficial, and  the  sebaceous  glands  particularly  are  affected.  The 
surface  is  somewhat  raised,  the  centre  of  the  diseased  patch  is 
pale  and  sinks  in.  The  tubercles  form  late,  if  at  all.  The  most 
common  site  of  the  disease  is  under  the  eye. 

Elephantiasis  of  the  Greeks,  the  true  leprosy,  is  distinguished  by 
tubercles,  from  the  size  of  a  pea  to  that  of  a  walnut,  of  reddish, 
or  whitish,  or  bronze-like  hue,  which  slowly  ulcerate,  and  which 
are  preceded  by  erythematous  patches.  Like  lupus,  these  tuber- 
cles have  the  structure  of  granulation  tissue.  Often,  too,  there 
are  symptoms  of  defective  innervation,  especially  deficient  sensa- 
tion of  the  surface,  the  nerve-trunks  are  invaded  and  cutaneous 
eruptions  in  their  course  result,  and  the  blood  is  seriously  af- 
fected. The  face  is  most  frequently  the  seat  of  the  malady,  and 
becomes  very  much  thickened  and  disfigured ;  similar  changes 
may  also  be  seen  in  the  limbs.  When  marked  nodules  form,  the 
skin  is  decidedly  discolored,  often  copper-colored,  and  the  face  is 

*  McCall  Anderson,  Journal  of  Cutaneous  Medicine,  vol.  i. 


864  MEDICAL    DIAGNOSIS. 

distorted,  and  has  a  fierce  expression.  Sometimes  anaesthesia  is 
the  main  symptom,  and  the  uneven  thickening  may  occur  in  cir- 
cular patches  like  psoriasis,  but  without  tubercles,  and  markedly 
anaesthetic.     The  disease  is  often  hereditary. 

Hypertrophies. — There  are  many  forms  of  these,  according 
to  whether  the  connective  tissue,  the  epidermis,  the  arteries  and 
veins,  or  the  lymphatic  vessels  are  affected.  I  shall  notice  par- 
ticularly two;  and  first,  elephantiasis  Arabum. 

The  Barbadoes  leg,  or  elephantiasis  of  the  Arabs,  is  an  enormous 
increase  in  size  of  the  limb,  usually  dependent  upon  an  indurated 
swelling  of  the  subcutaneous  tissues,  with  some  alteration  of  the 
skin  proper.  The  tumefaction  may  be  in  swellings  separated  by 
deep  furrows,  giving  somewhat  of  a  tuberculated  look  to  the  part, 
or  it  may  be  uniform ;  it  chiefly  attacks  males,  and  gives  rise  to 
great  deformities.  Similar  in  the  structure  it  principally  affects  is 
the  extraordinary  induration  of  the  cellular  tissue,  to  which  the 
name  of  sclerema  or  scleroderma  has  been  given.  Now,  sclerema 
may  be  partial  or  general,  affecting  nearly  the  whole  body.*  The 
skin  is  dense  and  hard,  and  in  the  true  skin  and  the  subcutaneous 
tissue  the  fibrous  elements  are  much  increased.  The  true  skin 
shrinks  and  binds  down  the  parts  beneath.  The  disease  is  generally 
symmetrical,  and  is  much  more  common  in  women  than  in  men. 
It  frequently  coexists  with  feeble  health ;  and  in  time  the  internal 
organs  become  affected,  or  these  may  be  from  the  first  deeply 
implicated.f 

I  had  some  years  since  a  marked  case  of  this  strange  affection 
under  my  charge  at  the  Pennsylvania  Hospital,  in  a  woman,  forty- 
two  years  of  age,  who,  admitted  with  oedema  of  the  feet,  was  at 
the  same  time  noticed  to  have  a  swelling  of  both  wrists  and  fore- 
arms as  well  as  of  the  cheeks.  The  swelling  was  firm  and  resist- 
ant, and  did  not  pit  on  pressure.  The  skin  covering  it  was  very 
smooth,  and  of  redder  hue  than  at  other  portions  of  the  body ; 
there  was  well-preserved  sensibility.  The  oedema  disappeared 
from  the  feet,  but  the  signs  of  the  indurated  cellular  tissue  did 
not  leave  the  affected  parts.     On  the  contrary,  the  condition  of 

*  A  full  collection  of  the  reported  cases  is  given  by  Van  Harlingen,  Araer. 
Journ.  of  Syphilography  and  Dermatology,  1873. 
f  Harley,  Medico-Chir.  Trans.,  1877. 


DISEASES    OF   THE   SKIN.  865 

these  parts  became  worse,  though  the  general  health  was  excellent, 
all  the  internal  viscera  being  in  a  normal  state.  Gradually  the 
hands,  particularly  the  fingers,  were  found  to  be  more  and  more 
resisting  and  immovable,  and  she  could  scarcely  bend  them  ;  occa- 
sionally they  were  the  seat  of  pain.  The  skin  lost  all  suppleness, 
and  could  not  be  raised  up.  At  no  time,  while  under  observation, 
was  albumen  present  in  the  urine.  She  left  the  hospital  unim- 
proved by  the  sulphur  baths,  the  bichloride  of  mercury,  and  the 
various  other  alteratives  she  took ;  and  I  afterward  learned  that 
she  died  of  an  acute  pleurisy  succeeding  an  attack  of  acute  men- 
ingitis, from  which  she  had  not  wholly  recovered.  Prior  to  her 
death,  so  great  was  the  pressure  exerted  by  the  dense  and  con- 
tracting cellular  tissue  that  dry  gangrene  of  a  finger  ensued,  as 
well  as  of  a  toe,  the  disease  having  also  been  noticed  in  the  lower 
extremities.  In  truth,  the  progress  of  the  whole  affection  was  in 
its  effects  on  the  adjacent  muscles  similar  to  those  produced  in  cir- 
rhosis by  the  increased  and  indurated  cellular  tissue.  She  died 
about  one  year  from  the  beginning  of  the  complaint.  Examined 
after  death,  the  skin  over  the  diseased  parts  was  firmly  united  by 
the  dense  and  augmented  areolar  textures  to  the  muscles  beneath : 
thus,  of  necessity,  their  motions  had  been  interfered  with. 

There  is  a  form  of  enlargement  of  the  leg  to  which  we  may  here 
briefly  refer, — one  in  which  the  overgrowth  of  the  affected  limb 
is  associated  with  disease  in  the  lymphatic  system.  Vesicles  form, 
which  are  connected  together  by  ridge-like  elevations,  and  which 
from  time  to  time  discharge  a  chylous  fluid.*  The  subcutaneous 
lymphatics  near  the  groin  are  usually  found  to  be  distended. 

Parasitic  Diseases. — These  may  be  caused  by  the  presence 
either  of  parasitic  animals  or  of  plants.  To  affections  of  the 
former  origin,  or  to  the  epizoa,  belongs  especially  scabies;  though 
the  various  forms  of  lice  producing  the  ailment  presenting  for  the 
most  part  a  pruriginous  eruption  with  little  hemorrhagic  marks 
— phtheiriasis — must  be  alluded  to.  The  other  animal  parasite, 
the  entozoon  or  demodex  folliculorum,  inhabits  the  sebaceous  and 
hair  follicles,  but  does  not,  so  far  as  is  known,  cause  disease. 

The  complaints  associated  with  the  vegetable  parasites,  the  epi- 
phytes, or,  as  those  on   the  skin   are  called,  the  dermatophytes, 


*  "W.  H.  Day,  Transactions  of  Clinical  Society  of  London,  vol.  ii.,  1869. 

55 


866 


MEDICAL    DIAGNOSIS. 


also  known  by  the  generic  name  of  tinea,  are  chiefly  favus,  men- 
tagra,  pityriasis  versicolor,  and  some  of  the  forms  of  ringworm, 
tinea  circinata,  and  tinea  tonsurans.  Pellagra,  also  supposed  to 
be  due  to  a  vegetable  parasitic  growth,  is  not  an  affection  met 
with  in  this  country.  Nor  does  the  presumed  parasitic  fungus 
lodge  in  the  skin.  It  is  said  to  be  found  in  diseased  Indian  corn 
or  maize,  which,  when  eaten,  causes  the  general  cachexia  and  cuta- 
neous eruption  which  characterize  the  malady,  of  which  the  erup- 
tion moreover  is  determined  by  exposure  to  the  sun. 

Scabies,  or  the  itch,  is  owing  to  the  acarus  scabiei.  This  bur- 
rows into  the  skin,  particularly  between  the  fingers  and  between 
the  toes,  about  the  wrists,  and  on  the  buttocks  and  abdomen  and 
the  upper  part  of  the  penis.  The  channels  produced  are  gener- 
ally somewhat  curved,  and  may  be  traced  as  whitish  or  more 
generally  black  streaks  several  lines  in  length,  in  the  situations 
just  indicated.  The  disease  is  attended  with  excessive  itching, 
which  is  increased  at  night,  and  with  the  eruption  of  conical 
vesicles,  or  even  of  a  marked  eczema  and  of  papules  and  pustules; 
most  of  this  rash  is  due  to  the  irritation  of  scratching. 


Fig.  55. 


A  female  acarus,  taken  from  a  photograph  from  nature ;  magnified 
220  diameters.    The  ventral  surface  is  shown. 

At  the  close  of  our  civil  war  we  had  a  form  of  itch  very 
prevalent  in  this  country,  which  was  spread  far  and  wide,  as  is 
presumed,  by  contact  with  the  troops, — the  so-called  army  itch. 
It  was  a  chronic  and  distressing  affection,  and  no  age  or  social 
state  was  exempt  from  it.     Indeed,  so  prevalent  was  it  that  it 


DISEASES   OF   THE   SKIN.  867 

almost  appeared  as  an  epidemic.  The  itching  was  intense;  the 
eruption,  as  by  far  most  frequently  met  with,  was  like  prurigo, 
but  vesicles,  or  even  an  eczematous  condition  of  skin,  or  pustules, 
attended  the  intolerable  itching ;  and  in  cases  of  very  long  dura- 
tion the  appearance  of  the  skin  was  altered,  and  all  trace  of  a 
distinctive  eruption  was  gone.  The  eruption  was  seen  on  the  arm, 
forearm,  chest,  abdomen,  and  lower  extremities,  particularly  on  the 
ulnar  side  of  the  forearm  and  the  inner  aspect  of  the  thigh.  It 
was  sometimes  found  on  the  scalp,  but  very  seldom  in  the  groins, 
in  the  axilla?,  on  the  hands,  or  between  the  fingers.  It  was  bene- 
fited by  sulphur;  for  almost  all  the  preparations  recommended  for 
it  contained  sulphur.  Whether  it  was  due  to  the  same  acarus  as 
ordinary  scabies,  or  to  a  different  species,  I  am  unable  to  say. 

Favus  gives  rise  to  bright-yellow  umbilicated  crusts,  of  circular 
shape  and  smooth  surface,  which  often  form  yellow  rings  around 
the  hair-follicles  and  are  not  much  elevated  above  the  skin.  There 
is  no  discharge.  The  disease  rarely  affects  any  other  part  of  the 
body  than  the  scalp.  In  cases  of  doubt,  the  microscope  furnishes 
us  with  a  certain  means  of  diagnosis,  by  exhibiting  the  crypto- 
gamic  plants. 

The  vegetable  origin  of  mentagra,  or  sycosis,  is  not  so  satisfac- 
torily proved  as  that  of  favus ;  at  all  events  it  is  most  likely  that 
there  is  a  non-parasitic  as  well  as  a  parasitic  form.  The  distinc- 
tive marks  are  the  development  of  yellowish  pustules,  having  a 
bright-red  base,  around  the  roots  of  the  hair  of  the  beard.  The 
crusts  may  run  together.  The  trichophyton  tonsurans  is  the  para- 
site met  with  in  tinea  circinata,  the  ringworm  of  the  body,  and  in 
tinea  tonsurans,  the  ringworm  of  the  scalp.  This  is  common  in 
children,  and  spreads  by  contagion.  It  exists  in  circular  scaly 
patches,  on  which  are  dry  broken  hairs.  In  ringworm  of  the 
body  the  patches  are  also  circular  and  scaly;  but  they  are  red 
and  very  itchy,  and  much  paler  in  the  centre  than  at  the  edge. 
Examining  the  scurf  we  find  the  fungous  growth. 

Pityriasis  versicolor  or  tinea  versicolor  occasions  those  yellow 
or  yellowish-brown  discolorations  which  may  be  not  unfrequently 
seen  on  various  parts  of  the  body.  The  affection  is  common  in 
women,  especially  in  pregnant  women.  The  microsporon  furfur  of 
Eichstadt  is  the  parasite  present  in  this  disorder;  and  it  is  found 
abundantly  in  the  scales  which  can  be  scraped  from  the  raised, 


868  MEDICAL    DIAGNOSIS. 

itching  patches.  In  pityriasis  affecting  the  scalp  we  may  also 
find  parasitic  growths  of  vegetable  nature  ;  and  they  are  often  the 
cause  of  baldness,  as  in  tinea  decalvans. 

Altered  Gland-secretions. — One  of  these,  seborrhea,  or 
increased  secretion  from  the  sebaceous  glands  mixed  with  epi- 
dermic scales,  has  already  been  alluded  to.  It  is  especially  found 
on  the  scalp,  nose,  and  genitals,  and  is  often  seen  among  those 
who  have  menstrual  disorders.  It  is  unattended  by  itching;  the 
crusts  are  readily  removed  by  strong  alkaline  soaps,  and  the  skin 
beneath  is  healthy,  or  pale  and  glistening  or  slightly  reddened. 

Where  the  sebum  is  retained  in  the  follicle,  giving  rise  to 
little  prominences,  apt  to  be  discolored  by  dirt,  and  without,  as 
happens  in  acne,  decided  inflammation  around  the  gland  and  its 
duct,  the  disorder  is  called  comedo.  The  plug  of  sebum  can  be 
easily  squeezed  out.  The  disorder  is  most  common  on  the  face 
and  shoulders  of  young  persons  of  lymphatic  temperament. 

The  sweat-glands  are  often  altered  in  their  activity,  and  excess- 
ive perspiration  results.  This  may  be  general,  or  confined  to  par- 
ticular localities,  as  to  the  hands  and  feet.  This  local  sweating  is 
often  offensive,  and  makes  the  parts  very  tender.  At  times  there 
is  sweating  of  blood  from  the  skin,  as  in  the  case  recorded  by  Hart.* 

Molluscum  presents  numerous  globular  or  nattish  nodules,  some- 
times seated  on  a  broad  base  or  attached  to  a  pedicle.  They  are 
due  to  excessive  enlargement  and  distention  of  the  sebaceous 
glands.  They  occur  chiefly  in  groups  on  the  face  and  neck,  or  on 
the  trunk,  have  often  a  doughy  feel,  vary  in  size  from  a  pea  to  a 
pigeon's  egg,  grow  even  to  be  larger,  show  no  tendency  to  in- 
flame or  ulcerate,  and  are  not  attended  with  increased  sensibility 
of  surface.  They  are  of  the  color  of  the  skin  or  of  brownish  hue. 
They  may  last  during  life  and  increase  slowly  without  affecting 
the  general  health.  There  is  a  variety  met  with  especially  in 
children,  which  has  at  the  top  or  side  of  each  tubercle  a  small 
orifice,  from  which  a  creamy,  fatty  fluid  can  be  pressed.  This 
variety  is  regarded  as  contagious;  though  there  are  many  who 
doubt  the  contagious  nature  of  "  molluscum  contagiosum."  The 
little  tumors  are  distinguished  from  fibromata  by  the  central  aper- 
ture, and  by  the  sebum  that  can  be  squeezed  out  of  them. 

*  Louisville  Medical  Journal,  Jan.  1875. 


DISEASES    OF   THE   SKIN.  869 

Nervous  Affections. — These  are  of  many  varieties.  Several 
of  these,  such  as  herpes  zoster,  have  already  been  considered.  I 
shall  now  merely  mention  that  the  large  group  of  itching  affec- 
tions where  no  very  obvious  local  affection  exists,  find  here  their 
place.  Such  are,  for  instance,  the  various  forms  of  'pruritus,  either 
local  or  general,  which  are  specially  apt  to  befall  elderly  persons. 
Sometimes  the  itching  is  very  violent  and  obstinate,  and  we  cannot 
trace  it  to  reflected  irritation,  though  this  is  often  its  cause.  Season 
influences  it  much ;  and  I  have  met  with  a  number  of  cases  of  the 
same  kind  as  those  described  by  Duhring  as  pruritus  hiemalis.  It 
happens  particularly  about  the  thighs  and  legs,  and  there  may  be 
prominence  of  the  hair  follicles. 

The  disorders  of  the  skin  which  we  have  been  considering  do 
not  always  occur  isolated  :  they  may  be  combined.  Again,  they 
are  altered  by  the  existence  of  a  special  taint,  as  by  the  syphilitic. 
Now,  without  making  any  attempt  to  describe  syphilitic  diseases 
of  the  skin,  I  may  briefly  state  that  they  differ  chiefly  by  their 
copper-colored  tint,  by  the  stained  aspect  they  leave,  and  by  the 
absence  of  pain  and  of  itching.  In  syphilitic  erythema  the  erup- 
tion runs  a  very  chronic  course,  and  is  very  distinct  generally  on 
the  trunk.  It  belongs  to  early  syphilis.  Syphilitic  lichen  has 
better-defined,  more  obvious  pimples  than  simple  lichen.  The 
ulcerations  in  the  pustular  affections  are  deeper  ;  while  in  the 
squamous  disorders  the  scabs  are  smaller  and  the  papules  larger 
than  in  the  non-syphilitic  eruptions.  Syphilitic  affections  of  the 
skin  are  very  apt  to  be  mixed,  and  light  is  thrown  on  them  by 
this  fact,  as  well  as  by  the  history  of  the  case,  the  sore  throat,  the 
falling  of  the  hair,  and  the  nerve  and  bone  pains. 


CHAPTER   XIII. 

POISONS   AND   PAKASITES. 

In  disorders  due  to  poisons  or  parasites,  the  morbid  phenomena 
are  clearly  occasioned  by  causes  introduced  into  the  system  from 
without.  Thus  they  agree  in  being  affections  of  external  origin ; 
and  as  regards  both  the  diagnosis  and  the  treatment,  our  chief  aim 
is  to  ascertain  precisely  to  what  foreign  substance  the  symptoms 
are  owing. 

POISONS. 

Cases  of  poisoning  are  presented  to  the  physician's  notice  under 
various  circumstances.  Sometimes  they  are  the  result  of  accident 
or  of  carelessness;  sometimes  the  life  of  the  patient  has  been 
attempted  by  himself  or  by  others.  I  cannot,  of  course,  enter 
here  at  any  length  into  the  subject  of  poisons,  but  shall  merely 
endeavor  to  set  forth  the  main  signs  by  which  the  consequences  of 
the  most  common  of  them  may  be  recognized  and  distinguished. 
And  for  this  purpose  it  will  be  convenient  to  consider  cases  of 
poisoning  as  divided  into  acute  and  chronic,  subdividing  these  two 
classes  again  according  to  the  character  and  effects  of  the  different 
noxious  substances.  Now,  as  regards  their  character  and  effects, 
various  arrangements  of  poisons  have  been  made  by  toxicologists, 
as,  for  instance,  into  irritant,  narcotic,  narcotico-acrid,  and  septic ; 
into  metallic  and  non-metallic ;  into  animal,  vegetable,  and  mineral. 
In  the  following  sketch  I  shall  not  adhere  closely  to  any  of  these 
arrangements,  but  shall  be  guided  by  them  only  to  a  certain  degree 
in  grouping  the  poisons  to  be  discussed. 

Acute  Poisoning. 

The  attack  comes  on  suddenly,  the  patient,  previously  in  perfect 
health,  having  taken  some  food,  drink,  or  medicine  which  has 
been  followed  by  the  urgent  symptoms.     And  it  is  always,  in  a 
870 


POISONS   AND    PARASITES.  871 

case  of  suspected  poisoning,  of  the  utmost  importance  to  be  able 
to  make  out  these  points. 

Irritant  Poisons. — The  chief  articles  which  give  rise  to  acute 
poisoning  belong  to  the  class  of  irritant  poisons.  The  symptoms 
are  generally  those  of  acute  gastritis,  attended  often  with  more  or 
less  inflammation  of  the  mouth,  the  fauces,  and  the  oesophagus. 
Sometimes  the  air-passages  may  be  involved,  either  directly  or  by 
sympathy,  and  we  find  hoarseness  and  cough.  Convulsions  are 
occasionally  observed,  and  collapse  is  apt  to  occur  sooner  or  later. 

The  acute  pain,  the  tenderness,  and  the  vomiting  come  on 
shortly  after  a  meal,  or  at  least  after  something  has  been  swal- 
lowed. This  distinguishes  the  acute  gastritis  caused  by  poisons 
from  idiopathic  acute  gastritis  or  from  acute  gastric  catarrh.  And 
sometimes  several  persons  are  similarly  affected,  a  circumstance 
always  strongly  in  favor  of  the  idea  of  poisoning.  From  perfora- 
tion of  the  stomach  or  intestines,  irritant  poisoning  is  discriminated 
by  noting  that  the  acute  signs  in  the  former  case  follow  upon  the 
manifestations  of  some  gastric  or  intestinal  affection ;  and  the  at- 
tending phenomena  of  collapse  are  not,  as  in  poisoning,  associated 
with  cramps  or  convulsions.  Cholera  resembles  poisoning  in  the 
suddenness  and  the  violence  of  the  attack,  but  is  distinguished 
by  the  rice-water  discharges  and  by  its  epidemic  character.  In 
strangulated  hernia,  the  comparatively  gradual  onset,  the  pain,  the 
tumor,  and  the  constipation  will  be  significant.  As  regards  the 
separation  of  those  cases  of  poisoning  in  which  blood  is  ejected, 
from  ordinary  hemorrhage  from  the  stomach,  we  find  that  pain  and 
purging  are  both  absent  in  the  latter,  while  in  irritant  poisoning 
they  are  well-marked  symptoms. 

Let  us  now  examine  some  special  poisons.  Strong  acids  are 
frequently  used  to  destroy  life.  Nitric  acid  stains  the  lips  and 
mouth  orange-yellow  wherever  it  touches  them;  the  matters 
vomited  are  very  acid,  and  act  upon  copper  or  tin,  with  the 
disengagement  of  reddish  fumes  of  nitrous  acid.  Sulphuric  acid 
stains  the  skin  or  mucous  membrane  white  or  grayish ;  the  pain  is 
excessive,  and  if  the  vomited  matter  be  mixed  with  a  solution  of 
nitrate  of  barium,  a  dense  white  precipitate  of  sulphate  of  barium 
is  thrown  down.  Muriatic  acid  is  less  irritant  and  corrosive 
than  sulphuric  acid.  It  is  recognized  in  the  ejected  substances 
by  causing  a  white  precipitate  with  nitrate  of  silver.     Oxalic  acid, 


872  MEDICAL    DIAGNOSIS. 

when  concentrated,  is  rapidly  fatal.  If  vomiting  occur,  the 
matter  ejected  may  be  tested  with  a  solution  of  lime,  when  the 
oxalate  of  lime  will  form  a  white  and  insoluble  deposit. 

The  strong  alkalies,  when  taken  into  the  stomach,  cause  inflam- 
mation of  the  organ  and  of  the  fauces  and  the  oesophagus.  Am- 
monia may  also  induce  violent  nervous  symptoms,  similar  to  those 
of  tetanus ;  its  vapor  sometimes  acts  powerfully  on  the  air-passages. 

Iodide  of  potassium,  iodine,  bromine,  and  chlorine  are  all  capable 
of  destroying  life  by  their  intensely  irritant  effect.  Phosphorus, 
which  is  not  unfrequently  taken  as  a  poison,  imparts  to  the  breath, 
to  the  faeces,  and  even  to  the  urine,  an  alliaceous  smell,  and  makes 
them  luminous  in  the  dark.  It  acts  as  an  irritant,  causing  obsti- 
nate vomiting  and  purging,  pain  at  the  epigastrium,  rapid  and 
weak  pulse,  jaundice,  and  unquenchable  thirst.  The  local  pain 
and  inflammation  are  usually  extreme,  and  collapse,  with  or  with- 
out convulsions,  comes  on  early.  In  some  cases  painful  cramps 
in  the  limbs  occur,  and  various  disturbances  of  sensibility,  and, 
later,  violent  delirium  and  convulsions  eventuating  in  coma  and  in 
death.  In  other  cases  hemorrhage  is  a  striking  feature,  the  blood 
is  very  fluid,  and  issues  from  all  the  passages,  and  petechias  form 
beneath  the  skin.  The  temperature  remains  normal  until  near 
death.  The  pulse  becomes  feeble  and  small ;  the  first  sound  of 
the  heart  almost  disappears. 

Jaundice  is  a  constant  symptom ;  it  seldom,  however,  comes  on 
before  the  third  day,  and  is  never  intense  ;*  it  may  be  associated 
with  urticaria.  The  spleen  increases  in  size  simultaneously  with 
the  liver.  The  urine  becomes  very  scanty.  Albumen,  blood,  and 
fibrinous  casts  are  occasionally  present  in  the  secretion,  and  the 
biliary  coloring-matter  usually ;  urea  is  very  defective.  In  cases 
of  phosphorus  poisoning,  acute  and  extreme  fatty  degeneration  of 
the  tissues  happens.  It  occurs  with  astonishing  rapidity.  It  has 
been  seen,  in  the  bodies  of  persons  poisoned  by  phosphorus,  within 
so  short  a  period  as  forty-eight  hours,  and  has  been  found  to  affect 
the  heart,  the  smaller  blood-vessels  and  capillaries,  the  liver,  the 
kidneys,  the  glands  of  the  stomach,  and  the  voluntary  muscles.f 

*  Schraube,  Schmidt's  Jahrbiicher,  quoted  in  New  Sydenham  Society's 
Retrospect  for  1867-8,  p.  449;  Naunyn,  in  Ziemssen's  Cyclopaedia,  states  the 
reverse. 

•j-  Tardieu,  Etude  medico-legale  sur  l'Empoisonnement,  1867.  p.  445. 


POISONS   AND    PARASITES.  873 

Various  salts  of  potassium,  copper,  zinc,  silver,  lead,  and  iron 
occasionally  cause  death.  They  act,  for  the  most  part,  as  irritants 
merely ;  but  some  of  them  are  powerfully  astringent,  and  even 
caustic,  as,  for  instance,  the  chloride  of  zinc  or  the  nitrate  of  silver. 
If  the  toxical  phenomena  are  due  to  the  nitrate  of  silver,  the  stain- 
ing of  the  lips  may  afford  a  clue  to  the  nature  of  the  case.  There 
are  no  really  distinctive  symptoms  produced  by  large  doses  of 
arsenic,  of  antimony,  of  mercury,  or  of  their  compounds,  which 
are  among  the  best  known  of  irritant  poisons ;  the  peculiar  effects 
of  each  of  these  substances,  when  insidiously  introduced  into  the 
economy,  will  be  presently  alluded  to.  In  acute  arsenical  poison- 
ing, besides  the  pain  and  the  gastro- enteric  symptoms,  convul- 
sions, palsies,  and  bloody  or  albuminous  urine  have  been  specially 
noticed. 

Among  animal  substances,  cantharides  has  sometimes  been  pro- 
ductive of  poisonous  effects;  strangury,  albuminuria,  more  per- 
manent than  that  produced  by  turpentine,  and  priapism,  are  the 
most  marked  symptoms ;  while  the  shining,  green  particles  of  the 
drug,  if  taken  in  substance,  have  been  detected  in  the  vomited 
matters. 

The  sausage  poison,  produced  by  partial  decomposition  of  the 
fatty  part  of  sausages,*  occasions  colicky  pains,  and  severe  vomit- 
ing and  purging,  followed  by  chills,  great  prostration,  and  delir- 
ium. Similar  symptoms  are  produced  by  cheese  poisoning,  and, 
it  is  said,  by  partially  altered  eggs.  Besides  the  signs  of  gastro- 
intestinal irritation,  vertigo,  headache,  marked  anxiety,  and  mus- 
cular weakness  have  been  noticed  among  the  consequences  of 
eating  poisonous  cheese. 

The  vegetable  irritants  are  mainly  articles  commonly  used  as 
purgatives.  Thus,  elaterium,  aloes,  colocynth,  and  colchicum  have 
all  proved  fatal  when  taken  too  freely.  The  symptoms  do  not 
differ  materially  from  those  caused  by  other  poisons  of  this  class. 
Tobacco  and  lobelia  are  powerful  local  excitants,  occasioning 
emesis  and  purging,  with  a  speedy  collapse  of  the  system.  Savin 
not  only  produces  inflammation  of  the  alimentary  canal,  but  is  apt 
also  to  give  rise  to  strangury ;  it  is  most  frequently  resorted  to  with 
the  view  of  bringing  on  abortion.     Ergot  is  also  used  for  the  same 

*  Taylor,  On  Poisons,  3d  edit.,  1875. 


874  MEDICAL    DIAGNOSIS. 

purpose;  and  the  most  striking  symptoms  of  acute  ergot  poison- 
ing are  colic,  vomiting,  diarrhoea,  increased  salivation,  retardation 
and  weakening  of  pulse,  muscular  weakness,  and,  in  severe  in- 
stances, stupor.     The  poisoning  rarely  ends  fatally. 

Poisonous  fungi,  such  as  the  fly  fungus,  which  are  eaten  by  mis- 
take for  mushrooms,  produce  violent  symptoms  of  irritant  poison- 
ing attended  with  other  phenomena.  The  poisonous  agent  in 
the  fly  fungus  is  muscarine,  and  it  gives  rise  to  vomiting,  violent 
colic,  and  diarrhoea,  besides  slowing  of  the  pulse  and  the  breathing, 
and  violent  excitement  followed  by  stupor  and  somnolency.  The 
case  generally  lasts  two  or  three  days,  and  may  then  end  in  re- 
covery or  in  collapse ;  but  it  may  terminate  fatally  in  six  or  seven 
hours.  Finding  the  fungi  in  the  vomited  matter  or  in  the  stools 
greatly  facilitates  the  diagnosis. 

Narcotic  Poisoning. — The  symptoms  of  narcotic  poisoning 
vary  more,  according  to  the  special  article  taken,  than  those 
caused  by  irritants.  Narcotic  poisons  affect  chiefly  the  nervous 
system  and  the  circulation.  Many  of  them  produce  phenomena 
like  apoplexy  and  intoxication,  from  which  they  need  to  be  care- 
fully distinguished.  Narcotic  poisoning  is,  for  the  most  part,  of 
the  acute  form. 

Opium  is  by  far  the  most  important  of  narcotic  poisons.  It 
induces  giddiness,  stupor,  and  lethargic  sleep,  from  which,  how- 
ever, the  patient  can  at  first  be  roused,  if  sharply  spoken  to. 
Subsequently  this  sleep  deepens  into  coma  and  cannot  be  broken ; 
the  skin  is  relaxed  and  perspiring;  the  face  is  usually  pale;  the 
pupils  are  contracted  and  insensible  to  light ;  erections  of  the  penis 
are  common.  A  more  or  less  evident  odor  of  opium  may  often  be 
perceived  about  the  person  or  on  the  breath.  No  distinction  can 
be  drawn  between  the  effects  of  different  forms  of  this  poison  :  the 
stronger  the  preparation,  however,  the  more  marked  and  the  more 
rapid  will  be  the  progress  of  the  case.  Morphia,  codeia,  narcotine, 
and  the  other  alkaloids  give  rise  to  similar  symptoms,  but  the 
smell  of  opium  is,  of  course,  absent;  convulsions  are  most  likely 
to  occur  from  narcotine,  papaverine,  and  thebaine. 

The  diagnosis  of  opium  poisoning  from  apoplexy  and  from  the 
coma  of  urcemia  has  been  discussed  in  a  former  chapter.  We  may 
merely  recall  that  the  contracted  pupil  caused  by  opium  is  of  very 
great  significance,  and  does  not,  with  the  exceptions  there  referred 


POISONS    AND    PARASITES.  875 

to,  exist  in  the  other  states.  Moreover,  the  coma  of  apoplexy  is 
at  once  developed  ;  while  in  narcotic  poisoning  it  is  not  sudden, 
but  is  preceded  by  drowsiness  or  stupor,  which  gradually  passes 
into  coma.  These  phenomena  occur  also  in  the  same  sequence 
in  uraemia;  but  they  are  even  slower  in  their  progress,  and  are 
frequently  associated  with  convulsions  and  with  markedly  albu- 
minous urine  and  dropsy. 

From  acute  alcoholism  we  discriminate  opium  poisoning  chiefly 
by  the  absence  of  the  alcoholic  odor,  the  slow  respiration,  and  the 
presence  of  morphia  in  the  urine.  The  characteristic  smell  of 
chloroform,  the  great  pallor  of  the  countenance,  and  the  absence  of 
contracted  pupils  distinguish  chloroform  poisoning  from  opium 
poisoning. 

Chloral,  in  excessive  doses,  produces  heavy  sleep,,  with  con- 
tracted pupils  ;  but  they  dilate  on  awaking.*  There  is  some  re- 
duction of  temperature,  with  giddiness,  inability  to  walk  straight, 
double  vision,  and  headache,  in  cases  in  which  consciousness,  sen- 
sibility, and  muscular  power  have  not  been  entirely  suspended  by 
the  drug.  Weak  action  of  the  heart  is  another  of  the  dangers 
of  chloral  poisoning,  and  I  have  known  a  dilated  heart  almost 
paralyzed  even  by  small  doses.  In  some  instances  a  stage  of 
excitement  like  alcoholic  intoxication  precedes  the  narcotism. 

Benzine,  when  taken  internally,  occasions  muscular  tremor  and 
deep  sleep,  but  the  narcotic  depression  ends  in  recovery. 

Alcohol,  if  taken  in  large  quantities  and  not  much  diluted,  gives 
rise  to  symptoms  like  those  caused  by  opium.  The  eye  is  in- 
jected and  the  seat  of  ecchymosis  ;  the  pupils  are,  as  a  rule,  dilated 
and  very  sluggish  ;  the  breathing  is  irregular  and  stertorous ;  the 
temperature  lowered ;  the  insensibility  may  alternate  with  convul- 
sions ;  the  breath  has  a  strong  smell  of  alcohol  or  may  be  quite 
free  from  spirituous  odor.  This  absence  of  odor  of  the  breath, 
although  not  usual,  may  give  rise  to  a  confusion  between  alcoholic 
poisoning  and  apoplexy,  and  the  discrimination  of  these  conditions 
must  then  depend  in  some  measure  upon  evidence  furnished  by 
the  history  of  the  occurrence  of  the  insensibility,  and  by  the  pres- 
ence or  absence  of  the  signs  of  palsy. 

Belladonna,  or  its  active  principle,  atropia,  and  hyoscyamus 

*  Taylor,  On  Poisons,  3d  edit.,  187-5. 


876  MEDICAL    DIAGNOSIS. 

produce  more  marked  excitement  of  the  brain  than  opium  does, 
causing  delirium  of  active  kind,  perhaps  with  convulsions.  The 
pupils  are  greatly  dilated,  and  vision  is  singularly  deranged  ;  there 
is  intense  thirst,  with  great  dryness,  redness,  spasm,  and  burning 
in  the  throat;  the  breathing  is  rapid,  thus  differing  from  apo- 
plectic conditions.  The  temperature  is  always  lowered  ;  the  pulse 
becomes  quick  and  compressible ;  a  scarlet  efflorescence  may  hap- 
pen. The  surest  test  of  poisoning  by  atropia  is  to  take  some  of  the 
urine  passed,  and  with  it  to  dilate  the  pupil  in  the  eye  of  a  cat. 

Conium  occasions  stupor,  paralyzes  the  muscular  system,  and 
dilates  the  pupils;  there  is  dyspnoea,  while  the  heart,  though 
rendered  slower,  is  not  much  affected.  Convulsions  may  come  on. 
These  help  to  distinguish  conium  poisoning  from  curare  poison- 
ing, which  it  much  resembles.  In  the  latter,  however,  the  palsy 
is  greater. 

Carbolic  acid,  if  taken  in  poisonous  doses,  produces  rapidly 
dangerous  symptoms,  which  in  bad  cases  terminate  in  death  in 
a  few  hours.  Vomiting,  slow  pulse,  noisy  breathing,  loss  of  con- 
sciousness, deepening  into  profound  coma,  abolition  of  reflex 
movements,  cool  skin,  suppression  of  urine,  are  the  main  symp- 
toms. When  the  urine  is  obtained,  it  is  of  dark-green  or  black 
color ;  this  and  the  odor  of  carbolic  acid  about  the  patient  are  very 
significant  features. 

Aniline  poisoning  is  met  with  among  the  workers  in  factories 
in  which  the  aniline  colors  are  made.  It  is  the  breathing  of  the 
aniline  vapor,  especially,  which  occasions  the  toxic  effect.  Vertigo, 
headache,  a  sense  of  suffocation,  vomiting,  anaesthesia,  pain  in  the 
extremities,  somnolency,  and  a  dark  cyanotic  discoloration  of  the 
ears,  the  nails,  and  the  mucous  membrane  of  the  nose,  have  been 
especially  noticed. 

Hydrocyanic  or  prussic  acid  is  a  well-known  poison  ;  it  usually 
leads  to  convulsive  contractions  of  the  muscles  of  the  limbs  and 
trunk,  and  destroys  life  by  stopping  the  circulation  and  respira- 
tion. Sometimes  the  odor  of  the  acid,  resembling  that  of  bitter 
almonds,  is  perceptible  in  the  patient's  breath ;  but  too  much 
reliance  must  not  be  placed  upon  this  point.  Unfortunately,  the 
diagnosis  of  this  poison  has  generally  to  be  made  after  death,  for 
medico-legal  purposes. 

The  gases  arising  from  burning  coal,  and  the  fumes  of  charcoal, 


POISONS   AND   PARASITES.  877 

may  lead  to  death  by  asphyxia ;  and  a  knowledge  of  this  fact  has, 
particularly  in  France,  led  to  many  suicides.  In  those  cases  in 
which  the  asphyxia  has  not  a  fatal  termination,  yet  has  been 
decided,  disorders  in  the  peripheral  nerves  may  manifest  them- 
selves, either  by  the  signs  of  neuritis,  or  by  pain  and  swelling 
simulating  a  phlegmon,  or  by  vesicular  eruptions  in  the  course  of 
an  affected  vaso-motor  nerve.  The  peripheral  disturbances  may 
appear  immediately,  or  not  until  after  some  days.  The  signs  of 
disorder  of  the  vaso-motor  nerves  do  not  last  long ;  those  of  the 
motor  or  sensitive  nerves  have  a  longer  duration;  the  complaint 
induced  may  be  incurable,  extending  from  the  centre  to  the  per- 
iphery, or  in  the  reverse  direction  ;  or,  lastly,  the  affection  may 
cause  an  acute  ascending  paralysis.* 

Petroleum  taken  in  excessive  quantities  produces  giddiness, 
faintness,  and  palpitation,  with  tonic  and  clonic  convulsions,  con- 
tracted pupils,  hot  skin,  and  slow  pulse;  it  does  not  occasion  either 
stupor  or  vomiting ;  the  urine  has  an  aromatic  odor.  Recovery 
is  the  rule. 

Following  these  poisons,  which  are  in  the  main  narcotic  poisons 
or  belong  to  the  group  of  poisonous  carbon  compounds,  we  shall 
examine  some  forms  of  acute  poisoning  produced  by  certain  well- 
known  and  powerful  vegetable  poisons. 

Aconite  has  a  strongly  sedative  influence  upon  the  action  of  the 
heart,  brain,  and  spinal  cord,  as  well  as  an  irritant  action  upon 
the  alimentary  canal ;  slow  pulse,  giddiness,  delirium,  numbness, 
and  tingling  of  the  skin,  loss  of  power  in  the  legs,  with  formica- 
tion, tingling  of  the  tongue,  vomiting,  and  purging,  are  followed 
by  syncope  and  death. 

Digitalis  causes  dilatation  of  the  pupil,  generally  with  vomiting, 
often  with  purging  and  with  headache,  giddiness,  and  suppression 
of  urine;  its  chief  effect,  however,  is  upon  the  pulse,  which  is 
strikingly  lessened  both  in  frequency  and  in  force,  and  becomes 
irregular ;  the  action  of  the  heart,  too,  becomes  weak,  and  blood- 
pressure  is  diminished  ;  the  mind  is  clear,  though  there  is  great 
lassitude,  with  muscular  debility,  a  tendency  to  sleep,  and  at  times 
convulsions.  The  action  of  the  poison  generally  extends  over 
days.      Veratrum  viride,  now  so  extensively  used  in  this  country, 

*  Leudet,  Arch.  Gen.  de  Med.,  May,  1865. 


878  MEDICAL    DIAGNOSIS. 

resembles  digitalis  in  its  action.  It  markedly  reduces  the  pulse, 
and  gives  rise  to  vomiting,  to  great  prostration,  and  to  irregular 
breathing.     The  temperature  is  much  lowered. 

Calabar  bean  acts  as  a  direct  sedative  to  the  spinal  marrow, 
particularly  to  the  medulla,  and  produces  great  muscular  debility 
or  relaxation  or  even  paralysis,  extending  to  the  heart  and  respi- 
ratory muscles.  The  mental  faculties  remain  unaffected,  and  in 
this  it  differs  from  the  action  of  the  cerebral  sedatives.  It  is, 
however,  irritant  to  the  alimentary  canal,  causing  vomiting  or 
purging,  a  peculiar  epigastric  sensation  is  generally  experienced, 
and  increased  salivation  is  met  with.  Calabar  bean  contracts  the 
pupil  and  also  the  ciliary  muscle,  thus  making  the  eye  myopic* 
The  condition  of  the  eye  is  the  main  diagnostic  sign  that  distin- 
guishes poisoning  by  calabar  bean  from  that  by  curare  or  by 
conium. 

Strychnia  and  brucia,  the  active  principles  of  nux  vomica  and 
of  several  allied  plants,  give  rise  to  phenomena  strongly  resem- 
bling those  of  tetanus.  A  very  short  time,  however, — from  a  few 
minutes  to  an  hour  or  two, — will  determine  the  issue  of  a  case  of 
poisoning;  while  tetanus  may  run  a  course  of  several  weeks.  The 
first  symptoms  of  strychnia  poisoning  are  apt  to  be  a  sense  of 
suffocation  and  dyspnoea  followed  by  spasms  of  the  respiratory 
muscles,  by  starting  and  twitching  and  rigidity  of  the  arms  and 
legs,  especially  of  the  extensor  muscles,  but  not  by  lock-jaw ;  teta- 
nus, on  the  other  hand,  comes  on  with  setting  or  locking  of  the 
jaws,  and  the  limbs  are  not  at  first  affected  with  spasms  ;  indeed, 
the  arms  remain  throughout  nearly  free  from  them,  and  the 
paroxysms  of  spasm  do  not  follow  one  another  so  rapidly  as  in 
strychnia  poisoning,  and  are  of  shorter  duration.  Again,  idio- 
pathic tetanus  is  extremely  rare ;  almost  always  there  has  been  some 
wound  or  injury  as  a  proximate  cause  of  the  malady.  But  we 
need  not  pursue  these  points  of  diagnosis  further ;  they  have  been 
already  mentioned  in  connection  with  tetanus.  From  epilepsy 
strychnia  poisoning  differs  by  the  unimpaired  consciousness  ;  from 
hydrophobia,  by  the  absence  of  spasm  of  the  oesophagus  and  of 
the  terrible  dysphagia. 

Picrotoxin  also  produces  convulsions  which  may  be  mistaken  for 

*  T.  A.  Kobertson,  Edinb.  Med.  Journ.,  March,  1868. 


POISONS   AND    PARASITES.  879 

those  caused  by  strychnia.  But  they  are  not  of  a  reflex  nature, 
and  reflex  spasms  are  not  induced.  The  breathing  is  rapid;  the 
contraction  of  the  heart  is  retarded ;  there  is  often  somnolence. 

Chronic  Poisoning. 

When  the  patient  has  been  subjected  to  the  continuous  action  of 
a  noxious  substance,  the  case  is  said  to  be  one  of  chronic  or  slow 
poisoning.  Any  of  the  irritant  poisons,  given  in  small  and  re- 
peated doses,  will  keep  up  a  morbid  condition  of  the  stomach  and 
bowels  much  like  ordinary  chronic  inflammation. 

The  narcotics,  taken  in  the  same  manner,  act  upon  the  vaso- 
motor nerves  and  the  cerebro-spinal  system,  and  through  this 
upon  the  alimentary  canal,  so  deranging  digestion  and  nutrition 
as  even  indirectly  to  cause  death.  Opium  is  the  most  important 
of  the  articles  thus  used;  it  is  often  administered  to  infants  for 
the  purpose  of  quieting  their  cries,  and  the  frequent  repetition 
of  the  dose  induces  a  series  of  phenomena  closely  allied  to  those 
observed  in  the  adult.  With  the  effects,  on  the  mind,  of  opium 
taken  persistently  fur  the  sake  of  intoxication,  the  reading  world 
is  familiar  through  the  published  experiences  of  De  Quincey  and 
of  Coleridge. 

The  habit  is  here  and  in  Europe  generally  acquired  only  by 
persons  who  have  begun  the  practice  for  the  relief  of  some  painful 
affection  ;  in  the  East,  opium  is  used  much  more  commonly,  and, 
in  many  Oriental  countries,  to  smoke  it  is  a  favorite  amusement. 
Those  who  employ  it  constantly  are  pale,  or  have  a  sallow,  hag- 
gard countenance  and  a  dull  eye.  They  lose  their  power  of  will 
and  their  energy,  and  are  troubled  by  loss  of  appetite,  giddiness, 
anomalous  neuralgic  pains,  sleeplessness,  and  low  spirits,  which 
they  remove  by  resorting  to  the  opiate.  Though,  in  spite  of  the 
pernicious  custom,  the  general  health  may  remain  for  many  years 
good,  yet  sooner  or  later  it  gives  way,  and  the  opium-eater  dies 
worn  out ;  or  death  may  be  the  consequence  of  disease  of  the  liver, 
of  palsy,  or  of  inveterate  diarrhoea,  produced  by  long  addiction 
to  the  vice.  Persons  who  consume  large  quantities  of  opium  are 
apt  to  have,  from  time  to  time,  attacks  of  extreme  nervous  pros- 
tration, attended,  perhaps,  with  violent  headache,  and  requiring 
free  stimulation  for  their  relief.     The  employment  of  morphia 


880  MEDICAL    DIAGNOSIS. 

hypodermically  is  becoming  an  alarmingly  frequent  form  of  the 
opium  habit,  especially  among  members  of  the  medical  profes- 
sion. Besides  the  general  symptoms  of  chronic  opium  poisoning, 
we  may  have  extensive  ulcers  and  other  local  signs  of  skin  irrita- 
tion to  deal  with. 

Ether  and  chloroform,  habitually  made  use  of,  also  cause  serious 
disturbance  of  the  nervous  system ;  and  so  does  alcohol.  The 
abuse  of  spirituous  liquors  gives  rise  to  a  disorder  of  the  mental, 
motor,  and  sensory  functions,  producing  sleeplessness,  headache, 
giddiness,  hallucinations,  imbecility,  complete  loss  of  sensation  of 
one-half  of  the  body, — generally  with  the  history  of  a  preceding 
apoplectic  seizure, — disordered  vision,  and  palsies.  Chronic  alco- 
holism also  occasions  a  sensation  of  choking,  a  diminished  vitality, 
a  persistent  catarrh  of  the  gastro-intestinal  membrane,  a  tendency 
to  fatty  degeneration,  especially  of  the  liver  and  kidneys;  in  short, 
the  symptoms  often  met  with  in  drunkards,  and  constituting  the 
state  so  graphically  described  by  Huss,*  Marcet,f  and  Magnan|  as 
chronic  alcoholism.  Chronic  alcoholism  in  the  parent  may  produce 
epilepsy  in  the  child. 

Chloral  has  proved,  like  opium  and  like  chloroform,  a  very 
fascinating  drug  to  many.  And  the  signs  of  chronic  chloral 
poisoning  are  becoming  more  and  more  evident  as  the  use  of  the 
medicine  spreads.  I  have  encountered  a  number  of  instances. 
The  chief  symptoms  are  digestive  disorders,  impairment  of  intelli- 
gence and  of  memory,  persistent  drowsiness,  almost  stupor,  striking 
enfeeblement  of  will,  want  of  power  in  the  legs  nearly  amounting 
to  paralysis,  and  occasional  tremor.  I  have  known  delirium 
tremens  to  follow  its  use,  when  large  quantities  of  it  had  been 
taken  and  the  medicine  stopped.  Feeble,  irregular  action  of  the 
heart,  and  sweating,  I  have  also  found  among  the  symptoms  of 
chloral  poisoning.  An  erythematous  inflammation  of  the  skin  of 
the  fingers,  with  desquamation  and  ulceration  around  the  borders 
of  the  nails,  has  been  pointed  out  as  a  result  ;§  and  various  forms 
of  eruption,  such  as  urticaria,  lichen,  and  purpurous  spots,  as  well 
as  bed-sores,  have  been  observed  after  its  prolonged  use. 

*  Alcoholismus  Chronicus,  or  Chronic  Alcohol  Disease. 
f  On  Chronic  Alcoholic  Intoxication.     London,  1860. 
X  De  l'alcoolisme  des  diverses  formes.     Paris,  1874. 
\  Smith,  Lancet,  vol.  ii.,  1871. 


POISOXS   AND    PARASITES.  881 

Tobacco  used  in  excess  gives  rise  to  tremors,  to  giddiness,  to 
emaciation,  to  impaired  digestion,  and  to  intermittence  in  the 
pulse,  with  irregular  cardiac  action  and  palpitations,  which  may 
become  very  annoying  and  originate  the  belief  of  an  organic  dis- 
ease of  the  heart.  Like  the  persistent  abuse  of  alcoholic  drinks, 
tobacco  may  occasion  amaurosis  ;*  and  it  is  also  affirmed  that 
an  insidious,  obstinate  form  of  otitis  is  developed  in  inveterate 
smokers,  and  is  attended  with  very  minute  granulations  of  the 
pharynx,  nasal  fossa?,  tubes,  and  middle  ear.t  When  taken  in 
large  quantities  by  those  previously  unaccustomed  to  it,  tobacco 
l)roduces  colic,  diarrhoea,  weakness,  sleeplessness,  dull  hearing, 
vomiting,  difficulty  in  breathing,  cold  sweats,  feeble  action  of  the 
heart,  and  will  even  cause  collapse  and  death.  The  peculiar  odor 
of  tobacco  may  assist  us  in  the  diagnosis  of  tobacco  poisoning ; 
but  it  must  be  remembered  that  this  may  attend  other  morbid 
states  in  those  who  use  tobacco  largely. 

Ergot  long  continued,  particularly  when  taken  contained  in 
impure  flour,  gives  rise  to  the  well-characterized  disease,  chronic 
ergotism.  This  appears  mainly  in  two  forms  :  the  first  is  marked 
by  convulsions  with  disturbance  of  sensation ;  the  second  by  gan- 
grene ;  both  are  apt  to  show  themselves  in  epidemics.  In  the 
convulsive  form  there  is  at  first  formication,  which  lasts,  whether 
attended  with  anaesthesia  or  not,  throughout  the  whole  illness. 
Soon  muscular  twitchings  and  cramps  followed  by  painful  con- 
tractions happen,  and  the  convulsions  may  become  very  general. 
These  spasms  especially  affect  the  flexors  of  the  arm,  and,  unlike 
those  of  strychnia,  they  are  not  reflex  spasms.  There  is  no  fever; 
the  circulation  is  slow  and  feeble;  the  appetite  is  insatiable;  we 
find  nausea,  vomiting,  and  diarrhoea.  The  disease  generally  lasts 
one  or  two  months.  In  severe  cases  delirium  occurs  as  a  precursor 
to  death.  In  gangrenous  ergotism  the  same  symptoms  happen;  but 
in  addition  we  meet  with  gangrene  without  fever  or  signs  of  inflam- 
mation.    The  gangrene  may  be  in  the  extremities  or  in  the  face. 

Let  us  now  examine  some  of  the  features  of  slow  poisoning  by 
the  metals. 


*  Sichel,  Annales  d'Oculistique,  ilars,  1865,  quoted  in  Brit,  and  For.  !Med.- 
Chir.  Rev.,  July,  1865. 
j  Triquet,  quoted  ib.     Le  Briert,  Gazette  des  Hopitaux. 

56 


882  MEDICAL    DIAGNOSIS. 

Mercury,  in  any  of  its  preparations,  may  lead  to  chronic  poison- 
ing. The  month  is  inflamed,  the  gums  are  sore  and  swollen,  the 
salivary  glands  act  inordinately,  and  the  breath  is  very  offensive. 
Colicky  pains,  and  sometimes  diarrhoea,  occur.  Tremors  of  the 
limbs,  when  any  motion  is  attempted,  evince  disorder  of  the 
nervous  centres  ;  they  are  particularly  frequent  in  cases  where 
the  poison  has  been  inhaled  in  the  form  of  vapor,  come  on  by 
degrees,  and  are  associated  with  loss  of  power  of  locomotion  and 
with  digestive  disturbances.  The  tremors  may  be  incessant  and 
the  movements  involuntary,  like  those  of  chorea,  and  so  rapid 
as  to  prevent  the  patient  from  obtaining  rest  at  night.*  In  some 
cases  an  eczematous  affection  is  observed. 

Poisoning  by  mercury  is  generally  the  result  of  the  exposure  to 
its  action  incidental  to  certain  occupations,  such  as  glass-plating, 
gilding,  and  working  in  quicksilver-mines. 

Lead  poisoning  is  by  no  means  uncommon  among  painters, 
plumbers,  type-setters,  and  other  workers  in  lead.  Sometimes  it 
may  be  caused  by  accidental  circumstances,  as  when  the  patient 
has  drunk  water  passed  through  leaden  pipes,  or  taken  snuff  which 
has  been  impregnated  with  lead  for  the  purpose  of  coloring  it; 
poisonous  properties  are  said  also  to  be  acquired  by  snuff  wrapped 
in  lead-foil,  and  lead  poisoning  has  been  observed  after  the  use  of 
cosmetics,  and  among  those  engaged  in  the  manufacture  of  lucifer 
matches,  of  brushes,  of  lace,  or  working  in  glass  enamel  or  glass 
powderjf  and  from  eating  canned  fruit.J 

In  such  cases,  the  physician  may  have  to  depend  entirely  upon 
a  correct  appreciation  of  the  symptoms  for  the  diagnosis.  Pain 
and  uneasiness  in  the  course  of  the  colon,  constipation,  loss  of 
appetite,  and  emaciation  are  the  earlier  signs.  A  metallic  taste 
is  sometimes  perceived ;  the  breath  is  fetid,  and  the  tongue  pale 
and  furred ;  the  gums  are  almost  always  edged  with  a  blue 
line.  Colicky  pains  are  felt  from  time  to  time,  and  a  severe  and 
long-continued  attack  of  colic  may  form  the  culmination  of  the 

*  As  in  a  case  reported  by  Dr.  Taylor,  in  which  the  patient  died  from  the 
effects  of  the  poison,  without,  however,  having  presented  salivation  or  mer- 
curial fetor  of  the  breath,  or  a  blue  line  on  the  gums.  Guy's  Hospital  Reports, 
3d  Series,  vol.  x. 

f  Lacharriere,  Arch.  Gen.,  Dec.  1859. 

%  Phila.  Med.  Times.  May,  1874. 


POISONS    AND    PARASITES.  883 

disease.  The  muscles  atrophy;  electro-muscular  contractility  to 
the  faradic  current  is  greatly  diminished  ;  to  the  galvanic  cur- 
rent it  is  unaltered  or  increased  ;  the  sensibility  of  the  skin  is  but 
little  affected.  Occasionally  wrist-drop  or  paralysis  of  the  extensor 
muscles  of  the  forearm,  so  well  known  as  a  phenomenon  of  lead 
poisoning,  occurs  among  the  first  symptoms  ;  but  it  is  more  gen- 
erally preceded  by  one  or  more  attacks  of  colic.  TTe  also  find  at 
times  lesions  of  the  tendons  in  saturnine  palsy.*  Yet  as  regards 
this  palsy  we  must  bear  in  mind  that  a  paralysis  of  the  extensors 
may  occur  which  is  not  due  to  lead.f 

Another  manifestation  of  lead  poisoning  is  found  in  the  severe 
pains  in  the  joints  and  the  neighboring  muscles.  These  pains  have 
violent  exacerbations,  and  may  be  associated  with  cramps  of  the 
painful  muscles.  They  are  most  common  in  the  lower  extremity, 
especially  over  and  near  the  knee-joints.  There  is  no  evidence  of 
inflammation  of  the  affected  joints  and  muscles;  pressure  tends  to 
relieve  the  pains. 

Sometimes  there  is  evidence,  in  cases  of  saturnine  poisoning,  of 
grave  cerebral  disorder  ;  epileptiform  convulsions,  attacks  resem- 
bling apoplexy,  or  general  tremors  and  extended  paralysis  of  the 
muscles,  with  amaurosis  and  other  signs  of  nervous  disturbance, 
are  noticed.  Of  course  the  diagnosis,  under  these  circumstances, 
will  be  materially  assisted  by  an  accurate  knowledge  of  the  pre- 
vious history  of  the  patient  as  regards  exposure  to  the  action  of 
the  poison.  The  tremors  are,  like  those  caused  by  mercury,  pecu- 
liar in  ceasing  when  the  limbs  are  supported  or  at  rest.  There 
may  be  tremor  in  the  muscles  of  the  face,  which,  however,  are  not 
affected  by  paralysis.  In  instances  in  which  the  symptoms  of  lead 
poisoning  are  obscure  or  conflicting,  we  may  search  for  lead  in 
the  urine.  The  plan  of  Doremus,  which  consists  in  evaporating 
the  urine  in  a  porcelain  dish  with  nitrate  of  sodium,  and.  adding 
fuming  nitric  acid,  then  distilled  water  and  sulphuretted  hydro- 
gen, is  very  convenient. 

Another  result  of  lead  poisoning;  is  that  it  leads  to  the  form  of 
Bright's  disease  known  as  granular  degeneration  of  the  kidneys. 
This  is  very  apt,  again,  to  coexist  with  a  gouty  condition,  which, 

*  Medical  Times  and  Gazette.  May,  1868. 
t  St.  George's  Hospital  Eeports,  1868,  p.  86. 


884  MEDICAL    DIAGNOSIS. 

as  Garrod  has  shown,  is  one  of  the  results  of  the  absorption  of 
lead.  But  the  kidney  affection  may  be  found  whether  or  not  the 
joints  are  markedly  affected.  The  intertubular  or  fibrous  tissue 
of  the  organs  becomes  thickened  by  a  sort  of  chronic  inflamma- 
tion, and  depositions  of  urate  of  sodium  between  the  tubes  are 
not  uncommon. 

Copper  poisoning  gives  rise  to  dyspeptic  symptoms,  to  diuresis, 
to  loss  of  flesh,  to  lassitude  and  giddiness,  to  a  peculiar  greenish- 
blue  perspiration,  and  to  a  green  line  on  the  gums  and  teeth.  It 
is  said  that  workmen  in  copper  are  singularly  insusceptible  to 
cholera  or  choleraic  diarrhoea,*  and  that  wounds  in  them  heal  with 
extraordinary  rapidity. 

Arsenic,  administered  in  small  doses  for  a  lengthened  period, 
produces  a  state  of  chronic  inflammation  of  the  alimentary  canal. 
Conjunctivitis,  oedema  of  the  face  and  the  limbs,  in  some  instances 
associated  with  albuminous  urine,  irritability  of  the  stomach, 
diarrhoea,  sleeplessness,  increasing  weakness,  nervous  derangement, 
and  even  paralysis,  mark  the  progress  of  these  cases ;  the  hair  and 
the  nails  occasionally  fall  out,  and  there  is  much  frontal  headache. 
Similar  effects  are  noticed  to  follow  the  pernicious  habit  of  arsenic- 
eating,  and  will  be  also  encountered  among  persons  employed  in 
making  artificial  flowers  and  toys,  in  dyeing  cloths,  in  manufac- 
turing and  hanging  green  wall-papers,  or  engaged  in  the  sublima- 
tion of  arsenical  ores  ;  those,  too,  who  live  in  rooms  hung  with 
papers  containing  much  arsenic  have  exhibited  the  influences  of 
the  poison.  Besides  the  phenomena  of  internal  poisoning,  cuta- 
neous eruptions  occur  from  arsenic.  In  some  instances,  said  to 
be  not  uncommon  in  Russia,  f  paralysis  of  the  extremities  with 
muscular  atrophy  happens. 

The  inhalation  of  the  fumes  of  zinc  gives  rise  to  a  peculiar 
form  of  poisoning,  characterized  by  a  sense  of  weariness,  a  feel- 
ing of  tightness  in  the  chest,  and  by  attacks  of  shivering,  followed 
by  heat  of  skin  and  a  profuse  sweating-stage.  This  irregular 
form  of  ague  is  common  among  brass-founders.^ 

Bisulphide  of  carbon  produces  toxical  effects  of  a  singular  char- 

*  Clapton,  Clinical  Society's  Transactions,  vol.  iii. 
f  Scolosuboft',  Arch,  do  Phys.,  Sept.  1875. 
X  Greenhow,  Med.-Chir.  Trans.,  1862. 


POISONS   AND    PARASITES.  885 

acter,  conspicuous  among  which  are  gastric  disturbances,  inordinate 
appetite,  loss  of  muscular  strength,  a  cachectic  condition,  feeling 
of  icy  coldness  in  the  lower  limbs,  severe  cramps  in  the  calves 
of  the  legs,  impotence,  and,  in  severe  cases,  amaurosis,  impaired 
hearing,  hallucinations,  loss  of  memory,  and  complete  perversion 
of  the  intellect.*  These  phenomena  are  met  with  among  workers 
in  india-rubber. 

Phosphorus  is  often  seen,  particularly  among  those  who  work 
in  lucifer-match  factories,  to  give  rise  to  serious  lesions.  When 
produced  by  inhaling  the  vapor,  it  may  occasion,  as  acute  phos- 
phorus poisoning  does,  alteration  of  the  composition  of  the  blood, 
a  hemorrhagic  diathesis,  and  a  fatty  degeneration  of  several  organs, 
as  well  as  of  the  voluntary  muscles,  f  It  also  produces  chronic 
bronchial  catarrh,  but  especially  necrosis  of  the  jaw,  for  which 
the  whole  lower  jaw  has  been  removed. J  The  disease  begins  in 
carious  teeth,  and  may  extend  to  the  cranial  bones.  Osteophytes 
form  freely  in  the  affected  bones.  Phosphorus  taken  internally 
in  doses  that  gradually  exert  a  poisonous  effect  leads  to  chronic 
inflammation  and  thickening  of  the  stomach,  colicky  pains,  di- 
arrhoea, hectic  fever,  general  emaciation,  falling  out  of  the  hair, 
and  to  palsies,  which  are  generally  the  precursors  of  a  fatal 
termination. 

Animal  poisons. — These  may  give  rise  to  chronic  as  well  as  to 
acute  poisoning.  We  find,  for  instance,  syphilis,  gonorrhoea,  hy- 
drophobia, dissecting  wounds,  snake-bites,  acute  glanders,  and 
farcy, — all  disorders  exhibiting  the  effect  of  an  animal  virus. 
But  we  have  already  discussed  some  of  these,  as  far  as  is  admis- 
sible in  a  work  of  this  kind ;  and  of  the  others  it  need  only  be 
said  that  the  antecedent  circumstances  generally  place  the  diagnosis 
beyond  a  doubt. 

Yet  there  are  a  few  illustrations  of  animal  poisons  and  their 
effects  which  must  here,  however  briefly,  be  mentioned. 

One  of  these  is  the  malignant  pustule,  or  anthrax,  a  terrible 
malady,  which  is  the  cause  of  many  deaths  on  the  continent  of 

*  Delpech,  Mem.  de  l'Acad.  de  Medecine,  1856 ;  and  Heurtaux,  Kecueil  de 
la  Societe  Medicale  d'Observation,  1860. 

f  Lancereaux,  L'Union  Medicale,  1863. 

%  Cases  of  Hunt  and  Boker,  Araer.  Journ.  of  Med.  Sci.,  April,  1865 ;  Wells, 
New  York  Med.  Journ.,  Jan.  1866. 


886  MEDICAL    DIAGNOSIS. 

Europe,  and  which  is  identical  with  the  charbon  of  animals.  The 
disorder  is  also  prevalent  in  New  Mexico.*  It  is  communicated 
to  man  by  direct  inoculation;  or  by  means  of  the  skin  or  hair 
of  the  diseased  beast,  or  by  eating  its  flesh  ;  or  by  insects  which, 
sucking  the  poison  from  the  sick  animal,  implant  it  on  the  skin  of 
man.  The  poison  produces  a  red  speck,  which  develops  into  a 
vesicle,  under  and  around  which  an  extremely  hard  spot  forms 
that  becomes  gangrenous.  The  surrounding  skin  inflames,  new 
vesicles  or  pustules  spring  up,  and  the  gangrene  spreads  rapidly, 
the  patient  speedily  sinking;  or  the  death  of  the  parts  is  arrested, 
and  separation  takes  place  between  the  living  and  the  gangrenous 
textures.  In  some  cases  it  is  attended  with  extended  cederaatous 
swelling  and  infiltration  of  the  areolar  tissue  spreading  from  the 
anthrax  pimple.  It  is  remarkable  how  little  local  pain  attends 
the  grave  constitutional  disturbance,  and  the  signs  of  low,  irritative 
fever.  The  disease  is  found  on  the  exposed  portions  of  the  body, 
as  on  the  neck  and  hands.  It  has  been  traced  by  Davaine  to  the 
presence  of  filiform  infusoria,  bacteridia;  and  the  researches  of 
Pasteur  and  others  fully  confirm  this  view  of  its  origin. 

Closely  connected  with  malignant  pustule  is  the  so-called  "wool- 
sorter  s  disease."  The  wool  from  sheep  is  not  nearly  so  dangerous 
as  the  hair  from  the  goat,  the  alpaca,  and  the  camel.  The  mohair 
from  the  Lake  Van  district,  Asia  Minor,  is  the  most  dangerous. 
The  symptoms  may  be  those  of  malignant  pustule  with  secondary 
splenic  fever,  or  there  often  is  an  utter  absence  of  either  external 
or  internal  pustule,  f  The  manifestations  of  the  disease  are  fre- 
quently a  low  fever  with  secondary  abscesses,  pysemic  symptoms, 
and  pleuro-pneumonia.  The  complaint  is  a  dangerous  one,  and 
often  fatal ;  when  ending  in  recovery,  convalescence  is  slow. 

The  foot  and  mouth  disease  is  an  affection  from  which  especially 
children  suffer  who  have  drunk  the  milk  from  infected  cows.  The 
poison  produces  an  aphthous  stomatitis  with  digestive  disorder, 
and  frequently  also  a  vesicular  eruption  on  the  face  and  upon  the 
fingers  and  hands,  which  gradually  dries  into  browriish  scales, 
and  at  times  a  similar  eruption  between  the  toes.  The  disorder  is 
not  a  serious  one. 


*  A.  H.  Smith,  Anier.  Journ.  of  Med.  Sci..  April,  1867. 
t  Bell,  Lancet,  June  12,  1880. 


POISONS   AND    PARASITES.  887 

There  is  another  form  of  animal  poisoning  which  may  be  in 
this  connection  briefly  considered,  namely,  milk- sickness.  Now, 
its  phenomena  are  so  variously  described  by  writers  that  its 
characteristic  signs  are  difficult  to  define.  It  prevails  in  the 
southern  and  southwestern  portions  of  North  America,  and  is 
brought  on  by  drinking  the  milk  or  eating  the  flesh  of  cattle 
which  have  been  exposed  to  certain  influences  the  nature  of  which 
is  as  yet  unknown.  Gastritis  and  enteritis  seem  to  be  more  or 
less  blended  in  the  early  stage  of  this  disorder,  which  at  a  later 
period  is  said  strongly  to  resemble  typhus  fever.  The  symptoms 
more  especially  dwelt  upon  are  lassitude,  nausea  and  vomiting, 
with  a  sense  of  burning  at  the  epigastrium,  great  oppression, 
intense  thirst,  hot,  dry  skin,  obstinate  constipation,  and  obvious 
abdominal  pulsation.  If  at  all,  recovery  takes  place  very  tardily, 
the  tone  of  the  stomach  being  often  left  impaired  for  life. 

Besides  these  forms  of  animal  poisoning,  which  are  produced 
by  the  direct  contact  with  the  virus,  or  at  all  events  by  its  intro- 
duction into  the  system  through  the  stomach,  we  find  morbid 
states  occasioned  by  animal  poisons  which  arise  from  decomposing 
bodies  or  excretions,  or  from  the  crowding  of  many  together,  par- 
ticularly of  those  of  uncleanly  habits,  or  of  the  wounded.  These 
poisons  reach  the  blood  for  the  most  part  by  the  lungs,  in  the 
shape  of  poisonous  exhalations.  They  are  very  depressing  in  their 
action,  may  lead  to  low  fevers,  or  to  septicaemia,  and  in  the  case 
of  the  wounded  to  pyaemia  and  to  hospital  gangrene.  Persistent 
nausea,  too,  and  a  lowering  of  all  vital  energy  are  not  uncom- 
monly observed  in  those  who  breathe  continuously  the  foul  air 
under  the  circumstances  alluded  to, — as  in  hospitals  and  in  prisons 
in  which  thorough  cleanliness  is  not  enforced  and  due  regard  is 
not  paid  to  ventilation. 

In  some  persons  deleterious  emanations  from  the  human  body 
give  rise  to  a  form  of  toxaemia,  one  of  the  chief  features  of  which 
is  the  marked  anorexia  which  attends  the  great  debility.* 

The  exposure  to  animal  effluvia  may  also  excite  violent  diar- 
rhoea, or  even  symptoms  like  those  of  cholera,  certainly  like  those 
of  severe  attacks  of  cholera  morbus.     Of  the  occurrence  of  the 


*  See  Dr.  Hunt's  case,   described  by  bimself,  in  Pennsylvania   Hospital 
Reports,  vol.  i. 


MEDICAL    DIAGNOSIS. 

former  we  have  an  illustration  in  the  dissecting-room  diarrhoea, 
which  is  usually  attended  with  very  fetid  discharges,  and  may  be 
accompanied  by  colicky  pains,  by  nausea  and  vomiting,  and  by 
headache.  The  same  kind  of  diarrhoea  also  happens  in  those  who 
clean  privies,  or  who  are  exposed  to  the  emanations  arising  from 
sewers ;  or  dysentery  or  choleraic  attacks  may  follow  the  exposure. 
Nay,  as  in  instances  recorded  by  Becquerel,  the  instant  disengage- 
ment of  large  quantities  of  putrid  gases,  arising  from  bodies  far 
advanced  in  decomposition,  where  coffins  have  been  opened,  has 
caused  sudden  deaths,  or  resulted  in  so  serious  a  state  of  poisoning 
as  to  have  given  rise  to  very  grave  illnesses,  having  mostly  a  fatal 
termination.*  In  individuals  who,  in  consequence  of  their  voca- 
tion, are  habitually  brought  in  contact  with  animal  effluvia  and 
are  liable  to  inhale  noxious  gases,  besides  the  attacks  of  diarrhoea 
referred  to,  chronic  disturbances  of  the  stomach  and  liver,  with 
marked  impairment  of  the  general  health,  may  happen. 

PARASITES. 

Parasites,  properly  speaking,  are  organisms  which  become  sec- 
ondarily implanted  within  or  upon  the  body.  There  is  much 
room  for  doubt  concerning  several  of  them,  as  to  whether  they 
cause  disease  or  are  merely  its  concomitants.  Some  parasites  give 
rise  to  no  symptoms  at  all ;  many  occasion  phenomena  closely 
resembling  those  of  other  irritations.  In  any  case,  however,  the 
only  absolutely  convincing  evidence  of  the  presence  of  a  parasite 
is  obtained  by  seeing  it. 

Vegetable  Parasites. — The  chief  vegetable  parasites  have 
been  mentioned  in  connection  with  diseases  of  the  skin ;  the 
oidium  albicans,  present  in  thrush,  and  stated  to  have  been  met 
with  in  diphtheria,  as  well  as  the  sarcinse  ventriculi,  have  also 
been  alluded  to.  All  these  vegetable  growths  can  be  detected  only 
by  the  microscope;  and,  particularly  in  those  involving  the  skin 
or  hair,  it  is  of  the  utmost  use  to  employ  the  liquor  potassae, 
under  the  action  of  which  the  structures  become  transparent. 

So  far  as  is  known,  only  one  fungus  penetrates  the  internal 
tissues, — the  chionyphe  Carteri.    This  gives  rise  to  that  terrible 

*  Traite  dHygiene,  3d  edit.,  p.  218. 


POISONS    AND    PARASITES.  889 

disease  known  as  podelcorna,  or  the  fungus  foot  of  India, — a  com- 
plaint found  among  the  natives  of  India  who  go  about  with  naked 
feet.  The  fungus,  introduced  either  through  a  scratch  or  passing 
through  the  pores  of  the  skin,  soon  spreads,  eating  its  way  into  the 
bones  of  the  tarsus,  metatarsus,  and  into  the  lower  end  of  the  tibia 
and  fibula,  producing  a  species  of  caries,  or  rather  a  breaking  up 
and  absorption  of  the  osseous  tissues.  The  fungous  particles  or 
masses  are  generally  of  deep  black  color,  firm  and  globular,  and 
in  size  varying  from  a  pea  to  a  pistol-bullet ;  or  the  fungus  pre- 
sents the  appearance  of  sloughing  tissue,  and  exhibits  chiefly  white 
granules ;  or  it  consists  of  particles  of  pinkish  color.  In  any  case, 
the  foot  is  enlarged  about  the  ankle  and  over  the  instep ;  and  on 
either  side  of  the  ankle-joint,  and  on  the  dorsum  as  well  as  on  the 
sole  of  the  foot,  are  small,  soft  swellings,  having  pouting  openings 
that  lead  to  fistulous  canals  communicating  with  the  bones,  which 
they  perforate  in  every  direction.  The  fungous  mass  is  for  the 
most  part  situated  in  the  cavities  in  the  bones,  and  from  the  canals 
passing  to  them  transudes  a  discolored,  glairy,  or  purulent  and 
fetid  fluid.  The  toes  are  distorted,  and  the  muscles  of  the  leg 
atrophied ;  bnt  the  fungus  does  not  spread  up  the  leg.  The  ten- 
dency of  the  disease  is  to  cause  death  by  exhaustion ;  the  only 
remedy  is  amputation.* 

Animal  Parasites. — When  speaking  of  the  affections  of 
particular  structures,  some  of  these  intruders  have  been  alluded 
to, — those  found  in  the  skin  or  liver,  for  instance.  I  have  now 
to  consider  chiefly  such  as  inhabit  the  hollow  viscera,  certain 
solid  organs,  and  the  muscles.  But  in  so  doing  I  shall  men- 
tion only  those  of  greatest  import,  for  there  are  at  least  thirty- 
one  distinct  animals  which  in  some  phase  or  other  of  their  ex- 
istence infest  man,  and  a  number  of  these  reside  in  the  structures 
just  alluded  to.f 

*  See  Carter,  in  the  Transactions  of  the  Bombay  Medical  and  Physical 
Society;  and  on  Mycetoma,  or  the  Fungus  Disease  of  India,  London,  1874; 
and  Aitken,  Practice  of  Medicine. 

f  For  their  full  description,  see  the  excellent  works  of  Joseph  Leidy,  A 
Flora  and  Fauna  within  Living  Animals,  Smithsonian  Publications,  vol.  v.  ; 
of  Davaine,  Traite  des  Entozoaires  et  des  Maladies  vermineuses ;  of  Cob- 
bold,  Entozoa  ;  of  Leuckhart,  Die  Menschlichen  Parasiten,  Leipzig  ;  and  of 
Kiichenmeister,  Manual  of  Parasites. 


890  MEDICAL    DIAGNOSIS. 

Intestinal  worms  are,  perhaps,  the  most  common  of  all  para- 
sites. The  general  symptoms  induced  by  them  are  those  of 
intestinal  irritation  with  disordered  digestion.  The  appetite  is 
capricious;  the  bowels  are  irregular,  sometimes  constipated,  some- 
times relaxed  ;  the  abdomen  is  frequently  swollen  and  hard,  and 
the  seat  of  distressing  uneasiness  or  of  colicky  pains  ;  the  tongue 
is  furred;  the  breath  fetid;  and  there  is  constant  itching  about 
the  nostrils  and  anus.  The  patient,  furthermore,  grits  his  teeth 
during  sleep,  and  is  often  annoyed  by  nightmare.  Phenomena 
indicative  of  a  greater  or  less  degree  of  nervous  disturbance  are 
also  met  with  ;  they  may  range  from  mere  fretfulness  up  to  de- 
lirium, convulsions,  chorea,  epilepsy,  or  insanity. 

There  are  many  kinds  of  worms  known  to  infest  the  alimentary 
canal  of  man,  and  they  belong  to  the  order  of  nematode,  or  round 
worms,  or  to  that  of  cestoidea  or  tape-worms. 

The  round  worms  are  parasites  of  an  attenuated  or  cylindrical 
form,  and  present  these  varieties: 

1.  The  ascaris  lumbricoides,  or  round  icorm,  bears  a  consider- 
able resemblance  to  the  common  earth-worm,  from  which  it  is, 
however,  anatomically  different.  It  inhabits  the  small  intestine, 
sometimes  finding  its  way  into  the  stomach,  or  even  into  the 
oesophagus,  or  being  discharged  through  the  abdominal  parietes.* 
When  it  ascends  to  the  stomach  and  oesophagus,  it  causes,  before 
it  is  expelled  by  the  mouth,  sudden  attacks  of  fever  and  gastric  de- 
rangement, with  nausea  and  vomiting;  and  even  at  times  marked 
delirium. f  The  worms  have  been  known  to  be  so  numerous  as 
to  obstruct  the  intestine.  Calomel,  pinkroot,  chenopodium,  and 
other  purgatives,  given  singly  or  variously  combined,  will  dis- 
lodge or  destroy  the  parasite. 

2.  The  oxyuris  vermicularis,  thread-ioorm  or  seat-worm,  is  very 
small,  the  male  being  about  two  lines,  the  female  about  five  lines 
in  length.  The  parasite  is  white,  slender,  and  extremely  active; 
is  found  in  the  anus,  and  causes  intense  itching  of  this  part.  The 
annoyance  is  sometimes  such  as  to  excite  a  suspicion  of  the  ex- 
istence of  piles.  It  may  "creep  into  the  vagina,  giving  rise  there 
to  profuse  discharges ;  or  into  the  urethra.      It  affects  children 


*  Gamier,  L'Union  Medicale,  Oct.  1861. 
t  Schmidt's  Jabrlmchcr,  No.  10.  1808. 


POISONS    AND    PARASITES.  891 

frequently,  but  is  not  uncommon  in  adults.     Enemata  containing 
vinegar  or  turpentine  generally  afford  relief. 

3.  The  ascaris  mystax,  a  parasite  which  inhabits  the  cat,  may 
also,  as  Bellingham  and  Cobbold  have  proved,  infest  the  human 
body.  It  is  a  moderate-sized  nematode,  from  two  to  three  inches 
long,  though  the  female  may  reach  about  four  inches.  Its  head 
end  is  spear-shaped. 

4.  The  trichocephalus  dispar,  or  long  thread-worm,  is  detected 
in  very  large  numbers  in  the  ileum  near  its  termination,  or  in  the 
colon,  particularly  at  its  head.  It  has  been  found  in  persons 
laboring  under  typhus  or  typhoid  fever,  or  dying  from  cholera  or 
diarrhoea.  It  is  from  an  inch  and  a  half  to  two  inches  in  length, 
and  is  characterized  by  the  hair-like  appearance  of  the  head,  which 
is  generally  buried  in  the  mucous  membrane  of  the  intestine.  It 
is  not  a  common  parasite,  and  it  is  doubtful  whether  its  presence 
gives  rise  to  any  marked  derangement. 

The  tape-worms,  or  cestoidea,  are  jointed  entozoa,  of  a  ribbon- 
like form.  They  embrace  the  true  tape-worms,  or  tseniadse,  and 
the  bothriocephali.  Of  the  former  there  are  eight  varieties,  all 
of  which  have  been  found  in  man,  though  only  two — the  solium 
and  the  mediocanellata — are  at  all  common.  The  bothriocephalus 
latus  is  the  usual  species  of  bothriocephalus  met  with  in  the 
human  intestine. 

The  tamia  solium,  or  common  tape-worm,  consists  of  an  immense 
number  of  joints  in  connection  with  a  single  head.  It  may  attain 
an  enormous  length,  and  inhabits  chiefly  the  small  intestines. 
The  researches  of  Kiichenmeister,*  Von  Siebold,f  and  others 
have  shown  that  its  eggs  become  developed  into  the  cysticereus 
celhdosos  discerned  in  the  muscles  of  the  pig,  rabbit,  and  other 
animals  whose  flesh  is  used  as  food.  Cysticerci  have  also  been 
detected  in  the  muscles,  the  cellular  tissue,  the  brain,  the  spinal 
cord,  the  heart,  the  liver,  and  even  in  the  eye  of  man,  and  are  most 
commonly  met  with  in  middle  age  and  in  the  destitute.  They 
cannot,  as  a  rule,  be  diagnosticated,  except  they  be  in  positions  in 
which  they  can  be  seen  or  felt,  or  the  little  tumors  they  occasion 


*  See  Manual  of  Animal  and  Vegetable  Parasites,  translation  published 
by  Sydenham  Society,  1857. 

f  Origin  of  Intestinal  Worms,  ibid.,  1857. 


892 


MEDICAL    DIAGNOSIS. 


in  the  subcutaneous  tissues  are  extirpated  and  examined.  In  the 
brain  their  chief  symptom  is  violent  and  rapidly  increasing  epilepsy. 
Being  once  introduced  into  the  alimentary  canal,  they  find  there  a 
nidus  in  which  to  undergo  development  into  the  tape-worm. 

The  tape-worm  is  nourished  from  its  head,  the  newly-created 
segments  pushing  those  already  formed  before  them,  so  that  the 
caudal  extremity  is  the  oldest  portion  of  the  animal.  Each  seg- 
ment is  flat  and  rectangular,  and  contains  both  a  male  and  a  female 
organ,  the  orifices  of  which  are  joined  at  the  apex  of  a  lateral 

papilla.  In  the  tcenia  solium, 
the  papillae  are  arranged  alter- 
nately at  one  side  and  the 
other.  The  size  of  the  seg- 
ments increases  gradually  to- 
ward the  caudal  extremity,  the 
largest  being  three  or  four 
lines  in  breadth.     There  may 


Fig.  56. 


Fig.  57. 


Jg$g 


Heads  of  taenia?,  magnified,  except  the  small 
central  figure,  which   represents  the  head  and 
neck  of  ta-nia  solium,  natural  size.    The  figure 
Segments  uf  taenia  solium.     Drawn  from  a         to  the  left  is  the  taenia  solium,  to  the  right  the 
specimen.  mediocanellata. 


be  upward  of  eight  hundred  segments,  and  the  worm  may  measure 
above  ten  feet;  nay,  it  has  been  stated  even  to  be  above  thirty. 


POISONS   AND    PARASITES.  893 

Upon  the  head,  which  is  about  as  large  as  that  of  a  pin,  is  a  double 
circle  of  hooks  contained  in  sacs,  and  around  this  circle  are  arranged 
four  sucking-cups  or  mouths.  The  slender  neck  exhibits  no  seg- 
mentation. The  sucking-disks  in  the  tcenia  mediocanellata  are 
larger  than  those  in  the  taenia  solium,  but  the  head,  which  is  of 
blackish  appearance,  and  obtuse,  has  no  hooks. 

Taenia  occasions  disordered  digestion,  colic,  cramps,  a  feeling  of 
uneasiness  in  the  abdomen,  irritation  of  the  mouth,  nose,  and  anus, 
anaemia,  headache,  dizziness,  disturbed  sleep,  mental  depression, 
cough,  fainting-fits,  and  various  cerebro-spinal  affections,  such  as 
convulsions  and  epilepsy;  yet  there  are  no  absolute  data  for  the 
diagnosis  of  this  parasite,  except  its  appearance  in  the  discharges. 
In  order  that  relief  be  permanent,  the  head  must  be  expelled. 
Many  remedies  have  been  recommended  for  effecting  this,  among 
which  may  be  mentioned  pomegranate  bark,  extract  or  oil  of  male 
fern,  kameela,  koosso,  and  pumpkin-seeds. 

The  bothriocephalus  latus,  tcenia  lata,  or  broad  tape-worm,  differs 
from  the  common  tape-worm  in  having  no  lateral  papillae  alter- 
nately arranged,  but  a  single  one  at  the  centre  of  each  segment ; 
the  segments  themselves  are  much  broader,  and  Avith  the  breadth 
greatly  preponderating  over  their  length  ;  the  head  is  of  elongated 
form,  has  no  hooks  upon  it,  and  only  a  pair  of  fissures  instead  of 
the  four  mouths  of  the  taenia  solium,  and  we  find  no  traces  of 
joints  until  about  three  inches  from  the  head.  The  parasite  is  of 
yellow  or  grayish-white  color. 

JSehinococci  belong  also  to  the  family  of  the  taeniadae.  They 
may  take  up  their  abode  in  the  substance  of  almost  any  organ  in 
the  body,  and  are  the  immature  brood  of  a  species  of  taenia.  They 
consist  of  a  vesicle  having  at  one  portion  of  its  wall  a  head,  upon 
which  are  six  hooklets  circularly  arranged.  The  whole  animal  is 
surrounded  by  an  investing  membrane,  which  may  burst  and  allow 
it  to  escape  ;  the  term  hydatid  designates  the  enveloping  cyst.  It 
forms  when  the  taenia  embryo  has  bored  its  way  to  its  resting- 
place  in  the  liver,  or  has  been  carried  with  the  circulation  to  other 
organs.  The  echinococcus,  unlike  other  larval  taeniae,  retains  a 
more  or  less  globular  figure,  in  place  of  exhibiting  a  head,  neck, 
and  body.  When  the  echinococci  are  arrested  in  their  normal 
development  and  are  barren,  not  attaining  to  the  production  of 
scolices,  they  give  rise  to  cysts  with  walls  consisting  of  distinctly 


894  MEDICAL    DIAGNOSIS. 

developed,  concentric,  layers,  and  having  a  peculiar  gelatinous 
trembling, — the  so-called  acephalocysts  ;  and  the  same  may  be  said 
of  abortive  cysticerci,  embryonic  forms  of  taenia?,  which,  some  sup- 
pose, may  also  occasion  the  hydatid  cysts;  though  others  maintain 
that  the  hydatids  proceed  from  only  one  form  of  taenia, — the  taenia 
echinococcus. 

The  family  of  the  distomata,  belonging  to  the  order  of  fluke- 
like parasites,  is  not  at  all  uncommon  in  man. 

A  species  of  distoma,  measuring  from  eight  to  fourteen  lines  in 
length,  called  the  distoma  hepaticum,  usual  in  the  liver  and  gall- 
bladder of  the  sheep,  has  been  seen  in  the  human  liver  and  gall- 
duct,  and  also,  it  is  said,  in  abscesses  of  the  scalp.  Other  species 
of  distoma  have  been  found  in  the  portal  vein,  ureters,  kidneys, 
and  bladder,  and  upon  the  intestinal  mucous  membrane;  yet  in 
the  portal  vein  and  its  larger  branches — a  common  seat  of  the 
distoma — the  parasite  produces  little  or  no  appreciable  derange- 
ment; but  when  in  the  intestine,  it  may  give  rise  to  congestion  of 
the  membrane,  extravasation  of  blood,  and  the  symptoms  of  dys- 
entery. This  has  been  specially  noticed  of  the  distoma  haemato- 
bium, or  Bilharzia  haematobia,  a  worm  common  in  Egypt,  and 
which  has  been  found  to  be  the  cause  of  the  haematuria  prevalent 
at  the  Cape  of  Good  Hope*  and  at  the  Mauritius. 

Filarial  have  been  met  with  in  the  urine.  Lewisf  regards  the 
haematozoon  he  has  described  as  a  filaria.  The  ova  of  nematode 
worms  were  detected  in  chylous  urine  by  Salisbury.^  A  worm 
called  the  strongylns  gigas  has,  in  one  or  two  instances,  been  ob- 
served in  the  kidneys. 

The  parasites  which  chiefly  occupy  the  areolar  tissues  or  the 
muscles  remain  to  be  described.  Of  these  there  are  two  of  special 
importance. 

One  is  the  filaria  medinensis,  or  Guinea-worm.  This  is  a 
very  slender,  flat,  finely-ringed  worm,  which  introduces  itself 
into  the  subcutaneous  cellular  tissue:  here  it  grows  rapidly,  and 
gives  rise  to  swelling,  with  more  or  less  inflammation ;  and  some- 
times to  severe   constitutional   disturbance.      After   a   time    the 


*  John  Harley,  Medico-Chirurgical  Transactions,  vol.  xlvii. 

f  Lancet,  vol.  ii.,  187:!. 

J  American  Journal  of  the  Medical  Sciences,  1868. 


POISONS    AND    PARASITES.  895 

swelling  points,  breaks,  and  the  worm  may  be  laid  hold  of  and 
carefully  twisted  around  a  little  piece  of  stick  or  a  quill  until  it  is 
extracted  entire;  if  broken  off,  the  eggs  with  which  it  is  filled, 
getting  into  the  wound,  will  become  the  agents  of  fresh  mischief. 
Many  of  these  worms  may  be  found  in  the  same  patient,  occa- 
sioning great  annoyance  and  distress,  even  fatal  exhaustion ;  but 
it  is  stated  that  there  is  often  only  one  present.  The  number 
may  vary  between  this  and  fifty.  Some  worms  are  twelve,  others 
forty  inches  long,  or  even  more.  According  to  Busk,  the  para- 
site grows  in  the  human  areolar  tissue  at  the  rate  of  about  an 
inch  a  week.  Though  it  is  most  frequently  found  in  the  lower 
extremities,  it  has  been  observed  to  appear  in  the  socket  of  the 
eye,  in  the  mouth,  the  cheeks,  the  ears,  and  under  the  tongue  and 
the  scalp.  It  migrates  rapidly  from  one  part  of  the  body  to 
another.  Where  it  exists,  a  pricking  or  an  itching  heat  is  felt; 
a  vesicle  forms  when  the  worm  is  about  coming  to  the  surface, 
and  this  vesicle  opens,  leaving  an  angry-looking  ulcer,  in  the 
centre  of  which  the  parasite  shows  itself.  The  period  of  incuba- 
tion is  about  twelve  months  :  thus  a  year  elapses  before  the  Guinea- 
worm  makes  itself  manifest  in  the  human  body.*  The  disorder, 
common  in  Asia  and  in  Africa,  is  fortunately  one  with  which  we 
are  unacquainted. 

Trichina  spiralis. — This  parasite,  now  known  to  be  of  frequent 
occurrence  in  the  muscles  of  man,  and  to  give  rise  to  a  grave  dis- 
order, was  formerly  supposed  to  be  perfectly  harmless.  It  was 
discovered  by  Owen  in  1835  in  human  muscles  taken  from  the 
dissecting-room,  and  was  named  by  him,  as  it  was  as  fine  as  a  hair 
and  always  coiled  up  in  a  more  or  less  spiral  line,  trichina  spiralis. 
The  same  parasite  was  subsequently  found  in  animals,  as  by 
Leidy  in  the  animal  which  it  most  infests, — the  pig.  But  in  the 
observations  made,  certainly  in  those  made  on  man,  the  trichinae 
were  only  detected  in  their  cysts,  and  as  these  cysts  become,  after 
a  certain  period,  filled  with  a  calcareous  deposit,  which  leads  to  the 
extinction  of  the  worms,  the  whole  subject  of  their  presence  in  the 
human  body  was  not  looked  upon  other  than  as  one  of  curiosity, 
until  in  1860  Zenker  proved,  by  a  series  of  splendid  observations, 
that  trichinae  may  exist  free  in  the  muscles  of  man,  that  they  are 

*  Aitken's  Practice  of  Medicine,  vol.  i. 


896  MEDICAL     DIAGNOSIS. 

encapsnled  only  after  some  time,  and  that  they  are  the  cause  of  a 
very  serious  disease. 

The  first  case  was  that  of  a  servant-girl,  who  died  in  the  hos- 
pital at  Dresden  with  symptoms  extremely  like  those  of  typhoid 
fever.  She,  together  with  several  members  of  the  family  in 
which  she  lived,  and  the  butcher  who  had  killed  the  pigs,  had 
swallowed  the  meat  uncooked,  and  had  soon  afterward  been  taken 
sick.  At  the  autopsy,  her  muscles  were  found  to  be  full  of  tri- 
china?, which  were  not  yet  encapsuled.  One  of  the  hams  and 
some  of  the  sausages,  portions  of  which  she  had  eaten,  contained 
numerous  encysted  trichinae.  Thus  the  connection  between  the 
symptoms  and  their  originating  cause  was  clearly  traced.  It  was 
soon  verified  by  other  observations;  and  it  has  since  been  well 
understood  that  the  cases  previously  examined  were  cured  cases, 
which  had  falsely  given  rise  to  the  belief  of  the  supposed  innocu- 
ous character  of  the  parasite,  and  that  in  the  trichina  disease,  or 
trichiniasis,  we  find  one  of  the  most  dangerous  maladies  to  which 
the  human  frame  is  liable;  so  dangerous  that  whole  families  have 
perished  from  its  effects  amid  great  suffering,  and  that  in  the  small 
village  of  Hedersleben,  of  2000  inhabitants,  300  were  affected,  of 
whom  80  died.* 

The  parasite  is  always  introduced  into  the  body  by  eating  ham, 
pork,  or  sausages  made  from  the  flesh  of  pigs  containing  trichinae. 
It  is  very  probable  that  the  hogs  themselves  obtain  them  from 
rats,  in  which  they  are  extremely  common.  It  has  also  been 
stated  that  trichinae  may  exist  in  beef ;+  but  this  is  not  generally 
admitted. 

The  trichina  spiralis  is  the  juvenile  condition  of  a  small  nema- 
tode worm.  It  is  incapable  of  generation,  and  becomes  fruitful 
only,  whether  encapsuled  or  not,  when  introduced  into  the  intes- 
tine. After  being  swallowed,  if  it  be  encysted,  the  capsule  is 
dissolved,  and  the  parasite  remains  in  the  intestine,  where  it  rapidly 
grows  to  three  or  four  times  its  former  size,  and  within  two  days 
attains  its  full  sexual  maturity.!  By  the  sixth  day  the  female 
trichiua  contains  an  abundance  of  living  young,  and  begins  to 


*  Yirchow,  Die  Lehre  von  den  Triehinen,  p.  33. 

t  New  York  Medical  Journal.  July,  1866. 

J  Leuckhart,  Untersuehungen  uber  Trichina  Spiralis.     Leipzig,  1866. 


POISONS   AND   PAEASITES.  897 

throw  off  minute  embryos,  which  are  born  without  any  covering 
from  the  egg,  and  at  once  begin  to  migrate  to  the  muscular  struc- 
tures.   They  pass  to  them  through  the  intestinal  walls,  the  mesen- 


FlG 


Trichina  in  recent  human  muscle,  taken  the  thirteenth  day  of  illness.     (After  Dalton 

tery,  and  the  blood-vessels.*  When  they  reach  the  muscles  they 
grow  there,  but  do  not  generate  others.  A  single  female  trichina 
may  remain  in  the  intestine  for  three  or  four  weeks,  or  even  longer, 
and  may  give  birth,  it  is  estimated,  to  from  two  hundred  to  two 
thousand  embryos,  which  find  their  way  to  the  muscles ;  while  the 
trichinae  that  have  been  swallowed  never  pass  beyond  the  intestine. 
In  six  or  eight  weeks  at  furthest  the  intestinal  trichina?  have,  as  a 

*  Dalton,  Transactions  of  the  New   York  Academy  of  Medicine,   1864  ; 
Fiedler,  Archiv  f.  Heilk,  v.,  1864,  and  Heller,  in  Ziemssen's  Cyclopaedia. 


898 


MEDICAL    DIAGNOSES. 


rule,  died  and  left  the  intestinal  canal;  four  to  five  weeks  may  be 
stated  to  be  their  average  life.* 

When  the  young  trichina  arrives  in  the  muscles,  it  begins  at 
once  to  destroy  the  muscular  texture.  It  penetrates  the  sarco- 
lemma,  feeds  on  the  fibre,  particularly  on  the  primitive  fibrils, 
and  on  the  granules  and  disks  of  the  contractile  matter,  or  syn- 
tonine;  and  irritates  the  sarcolemma,  leading  to  its  gradual  thick- 
ening, also  to  an  increased  development  and  multiplication  of  the 
nuclear  elements,  and  to  an  exudation  which  finally  fixes  the 
worm  to  a  particular  spot.  Thus  is  formed  the  cyst,  which  en- 
capsules  the  parasite,  and  which  plays  such  an  important  part  in 
its  subsequent  destruction.  This  cyst  in  the  human  subject  is 
oval,  or,  more  generally  still,  spindle-shaped,  the  prolongations 
having  a  rounded  end,  and  in  its  centre  the  worm  lies  coiled  up. 
It  takes  a  month  or  months  for  the  cyst  to  form  completely, 
though  at  the  end  of  the  third  week  after  migration  the  inflam- 
matory irritation  has  reached  its  highest  point,  and  the  trichina  is 
by  that  time — Leuckhart  says  in  less,  in  fourteen  days — nearly 
or  entirely  full-grown.  Several  trichinae  may  wander  in  the  same 
track,  and  ultimately  be  enclosed  in  the  same  mass  of  exuded 
matter.  Two  are  not  unfrequently  seen  intimately  coiled  up,  and 
the  number  may  rise  to  five.f 

After  the  perfect  formation  of  the  cyst,  further  changes  take 
place  in  it.  The  masses  of  nuclei  in  the  spaces  at  both  extrem- 
ities of  the  capsule  become  of  green- 
ish hue;  dark  or  black  particles  of 
carbonate  of  lime  and  magnesium  are 
deposited.  The  calcareous  mass  ex- 
tends, and  gradually  covers  the  whole 
parasite,  while  around  the  prolonga- 
tions of  the  cyst  fat  cells  are  de- 
posited. The  whole  process  is  very 
destructive  to  the  flesh-worm,  and  it 
is  thus  that  the  disorder  is  cured.  But  it  is  apt  to  be  months 
before  this  result  is  accomplished.     Nay,  as  we  know  from  two 


Fig.  59. 


Trichina  capsule  with  shell-like  calca- 
reous deposits.    (After  Leuckhart.) 


*  Leuckhart,  op.  cit. 

f  Thudichum,  Blue  Book.     Seventh  Report  of  the  Medical  Officer  of  the 
Privy  Council,  p.  367. 


POISONS    AND    PAKASITES. 


899 


Fig. 


cases  recorded  by  Virchow,  neither  the  encapsuling  nor  the  calca- 
reous transformation  kills  the  worms  of  necessity,  at  all  speedily ; 
for  in  the  one  case  they  had  remained  alive  for  eight,  in  the  other 
for  thirteen  and  a  half  years  after  the  infection.* 

The  appearances  described  are  not  to  be  recognized  by  the 
naked  eye.  Indeed,  the  cysts  can  scarcely  be  said  to  be  visible 
except  after  the  calcareous  matter 
has  been  deposited  in  them,  when 
they  appear  as  very  small  gritty 
substances  scattered  over  a  piece  of 
muscle.  For  the  study  of  the  cyst 
a  low  magnifying  power  only  is 
requisite.  To  investigate  the  struc- 
ture of  the  worm  requires,  however, 
one  of  at  least  300  diameters.  The 
parasite,  which   is  truly  a   micro- 


scopical animal,  being  only  ^  to  ^ 
of  a  line  in  length,  and  about  -^ 
of  a  line  in  thickness,  will  be  seen 
with  this  power  to  have  an  ante- 
rior extremity  that  is  narrow  and 
pointed,  and  often  to  show  an  ali- 
mentary canal  beginning  by  a  mouth,  and  followed  by  an  oesoph- 
agus surrounded  by  cells.  The  cellular  body  extends  through  a 
considerable  portion  of  the  animal,  and  passes  into  the  less  com- 
plex intestinal  canal,  which  terminates  with  an  anus  at  the 
rounded  and  comparatively  thick  posterior  extremity  of  the  worm. 
In  the  posterior  third  of  the  trichina  lies  the  generative  appa- 
ratus, which  in  part  presents  a  dark,  granular  mass,  but  nothing 
else  marked,  since  in  the  trichinae  found  in  the  muscles  there 
are  no  developed  sexual  organs.  The  internal  structures  are  pro- 
tected by  a  thin  but  strong  integument  with  minute  grooves.  The 
male  intestinal  trichina  is  only  about  two-thirds  the  length  of  the 
female,  and  the  body  is  more  transparent. 

The  number  of  trichina?  in  the  muscles  may  be  from  several 
hundreds  to  as  many  millions.  Now,  in  accordance  with  their 
number  in  the  muscles,  with  the  character  of  the  changes  which 


Encapsuled  chalky  concretions  in  muscle, 
due  to  dead  trichina?.  Magnified  about 
thirty  times.    (After  Leuokhart.) 


*  Virchow,  op.  cit.,  p.  40. 


900  MEDICAL    DIAGNOSIS. 

there  take  place,  and  with  the  quantity  in  the  intestines,  will  vary 
the  extent  of  constitutional  derangement  and  the  signs  of  local 
irritation.  Thus  the  symptoms  and  the  dangers  of  trichiniasis  are 
not  always  the  same:  we  find,  indeed,  all  the  degrees  of  the  malady. 
When  merely  a  few  thousand  trichina?  occupy  the  muscles,  there 
are  chiefly  muscular  pains  with  stiffness  and  general  debility;  signs 
which  gradually  cease  as  the  worms  become  fully  encapsuled  and 
cretaceous  alterations  occur.  When  the  muscles  are  occupied  by 
many  millions  of  the  flesh-worms,  the  local  phenomena  are  much 
more  severe;  there  may  be  almost  complete  immobility  of  the 
whole  body,  the  muscles  of  respiration  and  of  deglutition  are 
implicated,  irritative  fever  and  the  general  cachexia  are  marked, 
and  the  patient  is  apt  to  perish  by  gradual  exhaustion,  or  in  con- 
sequence of  the  disordered  respiratory  function,  or  of  some  pul- 
monary complication.  The  presence  of  large  numbers  of  trichina? 
in  the  intestine  produces  diarrhoea,  vomiting,  abdominal  pain  and 
tenderness;  or  the  worms  may  shortly  after  being  swallowed  give 
rise  to  a  kind  of  cholera  morbus.  Should  the  signs  of  the  affec- 
tion not  appear  until  from  twenty-one  to  twenty-five  days  after  the 
use  of  the  infected  meat,  and  take  the  form  similar  to  acute  rheu- 
matism of  the  joints,  there  are  not  as  many  trichinae  present  as  in 
the  choleroid  or  typhoid  variety  of  the  malady, — Rupprecht*  has 
recently  told  us  from  five  to  ten  millions. 

Speaking  generally,  we  may  recognize  in  trichiniasis  three  stages : 
the  first,  lasting  about  a  week,  during  which  the  trichina?  are  being 
generated  in  the  intestines  and  in  which  we  find  only  signs  of  gastro- 
intestinal irritation ;  the  second,  the  passage  of  the  brood  into  the 
muscular  textures,  and  the  disturbances  it  there  occasions;  the  third, 
the  retrogressive  formation  which  fairly  sets  in  about  three  or  four 
weeks  after  the  beginning  of  the  second.  Xow,  it  is  this  stage 
which  yields  the  most  striking  manifestations  of  the  malady: — 
loss  of  appetite;  pasty  taste  in  the  mouth;  nausea  or  vomiting; 
dry,  somewhat  coated  tongue ;  diarrhoea ;  abdominal  pain  and 
meteorism ;  prostration ;  fever,  with  a  quick  pulse  and  copious 
sweating;  cedematous  swelling  of  the  face,  followed  in  grave  cases 
by  almost  general  anasarca;  sensitiveness  of  the  skin  and  the  mus- 
cles to  the  touch,  or  painfulness  when  the  latter  are  moved,  and 

*  Vierteljahrspchftft  fiir  Ges.  Med.,  Oct.  1880. 


POISONS   AND    PARASITES.  901 

their  contraction  and  difficult  motion  ;  dyspnoea ;  apathy ;  sleepless 

nights;  nocturnal  attacks  of  abdominal  neuralgia;  and  emaciation. 

Let  us  examine  some  of  these  phenomena  more  in  detail : 

The  fever  is  a  very  marked  symptom.     It  sets  in  early,  owing 

to  the  intestinal  irritation,  though  it  is  not  until  the  end  of,  or 

Ftg.  61. 


Trichina  spiralis.    Magnified  300  times.     (After  Yirchow.) 

after,  the  first  week,  after  therefore  the  migration  of  the  youno- 
trichinae  has  fairly  begun,  that  it  is  strikingly  developed.  It 
is  then,  except  in  those  cases  in  which  fresh  importations  of 
trichinae  from  the  intestine  in  considerable  numbers  produce  ex- 
acerbations, a  continuous  fever,  with  a  pulse  ranging  from  100  to 
130,  with  scanty  urine  and  profuse  perspirations  having  a  very 
unpleasant  odor,  and  which  may  continue  in  certain  parts  of  the 
body  after  the  general  sweating  has  entirely  ceased.  The  tem- 
perature is  increased  to  about  101°  Fahr.,  though  it  may  pass  to 
104°  and  105° ;  yet  it  does  not  as  a  rule  reach  the  high  heat  which 
is  observable  in  other  continuous  fevers,  particularly  in  grave 
cases.  But  it  is  especially  in  the  profuse  perspirations,  the  absence 
of  enlargement  of  the  spleen  and  of  an  eruption,  the  swelling  of 


902  MEDICAL   DIAGNOSIS. 

the  face,  the  muscular  symptoms,  and  in  a  very  red  color  of  the 
visible  mucous  membranes,  that  the  points  of  difference  lie  between 
the  febrile  excitement  of  trichiniasis  and  typhoid  fever , — a  malady 
which,  on  account  of  the  continuous  fever,  the  prostration,  the 
diarrhoea,  and  the  sudamina,  it  resembles.  In  light  cases  of  tri- 
chiniasis there  may  be  no  fever,  or  there  may  be  a  fever  more  of 
intermittent  or  remittent  character. 

The  oedema  marks  the  distinct  beginning  of  the  second  stage 
of  the  affection.  It  manifests  itself  first  in  the  eyelids,  about  the 
seventh  day  of  the  disease,  and  is  apt  to  be  attended  with  a  catar- 
rhal state  of  the  conjunctiva,  with  dilated  pupils,  great  suscepti- 
bility to  light,  diminished  power  of  accommodation,  and  pain  in 
moving  the  eye.  The  swelling  may  extend  over  the  whole  face, 
and  is  sometimes  associated  with  flushing.  It  is  uninfluenced 
either  by  the  sweats  or  by  the  diarrhoea;  but  lessens  generally 
very  much,  or  even  disappears,  though  it  may  vanish  in  a  few 
days,  after  lasting  eight  or  nine  days ;  at  the  same  time,  too,  the 
diarrhoea  is  apt  to  diminish,  or  even  gradually  to  cease.  But 
instead  of  the  oedema  subsiding,  it  may  extend  to  the  chin,  to 
the  arms  and  legs,  and  to  the  back ;  or  it  may  show  itself  ill  the 
extremities  subsequently  to  the  disappearance  from  the  face,  and 
shortly  afterward  become  perceptible  over  the  trunk.  In  some 
cases  an  anasarcous  condition,  beginning  at  the  ankles  and  extend- 
ing upward,  occurs  during  convalescence,  and  is  of  long  duration. 
It  is  then  probably  connected  with  the  state  of  the  blood ;  whereas 
the  oedema  happening  earlier  in  the  malady  is  thought  to  be  due 
to  the  pressure  upon  the  arteries,  exerted  by  the  parasites  and  the 
exudation  of  plastic  material  they  produce,  or,  in  accordance  with 
the  observations  of  Thudichum,  to  their  presence  within  the  lym- 
phatic spaces,  vessels  and  glands,  and  blood-currents.*  It  is  a 
striking  fact  connected  with  the  dropsical  swelling  of  trichiniasis 
that  it  is  not  associated  with  albumen  in  the  urine,  for,  except  an 
increased  quantity  of  uric  acid,  the  urinary  secretion  contains  no 
abnormal  ingredient.  The  quantity  of  urine  is  much  diminished. 
Boils,  acne,  and  ecthyma  are  often  noticed  after  the  oedema  has 
passed  away.f 

*  Thudichum,  loc.  cit.,  pp.  362  and  386. 

|  Meissner,  Schmidt's  Jahrbiicher,  No.  4,  1868. 


POISOXS   AXD    PARASITES.  903 

The  muscular  symptoms  begin  in  the  second  stage,  at  about  the 
tenth  clay,  with  pain  and  stiffness  in  the  limbs.  Soon  at  all  parts 
of  the  body  the  muscles  give  the  impression  of  being  swollen;  they 
are  extremely  painful  when  touched  or  moved ;  and  the  patient 
lies  in  consequence  as  quiet  as  possible,  or,  in  very  severe  in- 
stances of  the  affection,  like  a  paralyzed  person.  The  immobility 
is  also  partially  due  to  the  retracted  state  of  the  muscles  which 
occurs  in  bad  cases,  and  which  produces  a  condition  similar  to  a 
true  spasm,  manifest  for  instance  in  the  semiflexed  position  of  the 
extremities,  and  in  the  occasionally  present  rigid,  trismus-like  set- 
ting of  the  jaws.  The  disturbance  of  function  of  certain  muscles 
becomes  particularly  evident.  The  disorder  of  the  muscles  of  the 
eye  has  already  been  alluded  to ;  we  encounter,  besides,  impaired 
hearing  and  difficulty  of  deglutition  and  loss  of  voice,  from  the 
muscles  of  the  ear,  of  the  pharynx,  and  of  the  larynx  being 
filled  with  trichina?.  The  respiratory  muscles  are  commonly 
much  affected,  and  we  find  hurried  and  shallow  breathing,  and 
at  times  considerable  distress  in  respiration.  The  muscles  of 
the  heart  usually,  and  the  unstriped  muscles  of  organic  life  con- 
stantly, escape  infection ;  and,  as  the  trichinae  wander  to  the  front 
of  the  body  rather  than  to  the  back,  the  muscles  anteriorly  are 
more  infested  than  those  posteriorly.  A  flabby  condition  of  the 
muscles,  with  a  certain  want  of  power  and  painful  sensation  on 
motion,  has  been  noticed  as  an  early  symptom  and  preceding  their 
marked  implication.* 

The  marked  muscular  pain,  the  stiffness,  the  fever,  the  profuse 
sweats,  the  acid  urine,  simulate  the  signs  of  acute  rheumatism; 
but  we  find  in  trichiniasis  diarrhoea,  no  articular  swelling,  and  no 
heart-complications.  Error  is  more  apt  to  happen  with  reference 
to  acute  muscular  rheumatism.  But  the  signs  of  prostration  and 
of  gastro-intestinal  irritation  are  here  wholly  wanting. 

The  condition  of  the  respiratory  muscles  gives  rise,  as  already 
stated,  to  the  embarrassed  respiration,  but  it  is  not  the  only  cause 
of  the  pub nonary  symptoms.  Yet,  whether  it  alone  leads  to  con- 
gestion of  the  lung  and  to  bronchitis  or  pleuritis,  or  other  causes 
concur  in  producing  them,  it  is  certain  that  these  states  are  usual. 
They  are  not  uncommonly  combined  with  pneumonia,  which  ap- 

*  Kratz,  Die  Trichinen-Krankheit  im  Hadersleben.     Leipzig,  1867. 


904  MEDICAL   DIAGXOSIS. 

pears  suddenly,  and  selects  the  lower  portion  of  the  left  lung  by 
preference,  occurs  about  the  twenty-sixth  day  of  the  disease,  and 
is  apt  to  prove  fatal.  The  sputa  consist  of  dark  unmixed  blood ; 
and  the  pneumonia  is  thought  to  be  due  to  a  trichinous  embolism, 
the  clots  being  derived  from  thrombi,  which,  forming  in  the  venous 
system,  are  sent  through  the  heart  into  the  lungs.*  Limited  catar- 
rhal pneumonia  may  be  also  met  with. 

If  the  patient  escape  a  serious  pulmonary  complication,  if  he 
have  strength  enough  to  withstand  the  weeks  of  irritative  fever 
and  exhaustion,  he  enters  at  the  end  of  a  month  or  of  five  or  six 
weeks  of  suffering  upon  a  gradual  convalescence.  The  fever  de- 
clines ;  the  respiration  is  less  accelerated ;  the  perspirations  are  far 
less  copious  ;  the  urine  increases  in  quantity  ;  the  pains  decrease ; 
and  by  about  the  sixth  week  of  the  malady  the  patient  is  suffi- 
ciently free  from  pain  to  lie  on  his  side,  and  is  thus  able  to  sleep. 
The  pallor  of  his  countenance  gives  way  to  a  healthier  hue;  his 
appetite  becomes  insatiable ;  and  he  moves  his  limbs  with  more 
and  more  freedom.  But  it  is  a  long  time  before  he  regains  his 
full  strength,  or  his  muscular  power.  Indeed,  the  latter  may  be 
always  somewhat  impaired  ;  though  we  have  the  authority  of 
Rupprecht  for  the  statement  that  it  may  entirely  return,  and  per- 
fect health  be  recovered.  In  some  cases  convalescence  does  not 
set  in  for  four  months ;  in  others  it  is  greatly  retarded  by  boils, 
by  inflammation  of  the  lymphatic  glands,  and  by  the  gradually 
yielding  dropsy.  The  change  in  the  power  of  accommodation  of 
the  eye  to  distances  may  also  alter  but  slowly.  Children  are  apt 
to  convalesce  more  quickly  than  adults.  They  suffer,  in  truth, 
less  from  the  disease,  and  are  not  subject  to  it. 

Now,  the  diagnosis  of  the  strange  malady  has  been  made  evident 
while  discussing  the  symptoms.  At  first  the  signs  of  gastro- 
intestinal catarrh,  the  vomiting,  the  slight  fever,  the  perspiration, 
the  muscular  feebleness,  are  the  most  significant.  It  need  be  but 
further  pointed  out  that  the  early  manifestations  might  be  mis- 
taken for  irritant  poisoning,  and  that  we  can  tell  their  meaning  prior 
to  the  marked  development  of  the  phenomena  in  the  muscles 
only  by  the  detection  of  trichina  in  the  stools.     The  same  may 


*  Rupprecht,  Die  Triehinen-Krankheit  im  Spiegel  der  Hettstiidter  Endemie 
betrachtet,  1864. 


POISONS   AND   PAKASITES.  905 

be  said  of  cholera  morbus.  Again,  it  must  be  borne  in  mind  that 
in  some  cases  of  trichiniasis  the  first  manifestations  of  the  com- 
plaint do  not  happen  for  two  or  three  weeks  after  the  infected 
meat  has  been  eaten ;  and  that  in  others  it  runs  a  chronic  course 
and  the  whole  disease  is  very  protracted.  The  so-called  " sausage 
poisoning"  not  dependent  on  trichinae,  differs  from  trichiniasis  in 
its  rapid  course  and  in  the  quick  appearance  of  the  symptoms 
after  the  spoiled  sausages  have  been  partaken  of.*  There  is  a  pe- 
culiar disease  of  the  arteries,  periarteriitis  nodosa,  which,  with  the 
signs  of  acute  desquamative  nephritis  and  fever,  gives  rise  to  small 
swellings  under  the  skin,  to  rapid  loss  of  muscular  power  with  de- 
ficient electro-muscular  contractility,  and  to  such  severe  muscular 
pains  that  they  are  readily  mistaken  for  those  of  the  trichinous 
affection. f  But  the  history  of  the  ailment,  the  signs  of  the  thick- 
ening of  the  vessels,  and,  if  necessary,  an  examination  of  the 
muscles,  will  throw  light  on  the  cause  of  the  muscular  distress. 
Indeed,  in  any  instance,  no  matter  what  be  the  complaint  trichi- 
niasis may  simulate,  there  is  but  one  means  of  determining  the 
presence  of  the  flesh-worms  positively, — to  examine  a  piece  of 
muscle.  This  may  be  effected  by  cutting  down  upon  a  muscle 
and  removing  sufficient  of  its  structure  for  a  microscopical  ex- 
amination, or  by  using  Middeldorpff's  harpoon  or  Duchenne's 
trocar  to  accomplish  the  same  purpose, — modes  of  diagnosis,  it 
must  be  confessed,  of  an  aggressive  kind,  not  likely  to  be  readily 
submitted  to :  though  where  they  become  necessary  anaesthesia, 
general  or  local,  may  be  employed  as  a  preliminary  measure. 

Owing  to  the  oedema,  and  particularly  the  oedema  of  the  eye- 
lids and  face,  the  malady  may  be  confounded  with  BrigMs  disease. 
But  the  utter  absence  of  albumen  in  the  urine  distinguishes  it. 
The  physical  signs  separate  the  dyspnoea  it  occasions  from  that  of 
cardiac  disease;  and  the  sweats  and  the  muscular  symptoms  of 
trichiniasis  tell  us  what  we  are  dealing  with. 

The  chief  epidemics  of  trichiniasis  have  occurred  in  Germany  ; 
but  we  have  not  escaped  in  this  country. J     Nor  can  we  claim 

*  See  Falck,  in  Virchow's  Handbuch  der  Pathologie  und  Therapie,  vol.  ii. 
p.  328. 

■j-  Kiissmaul  and  Maier,  quoted  in  Schmidt's  Jahrbucher,  No.  8,  1868. 

J  See,  for  instance,  Dalton,  op.  cit.,  and  Medical  Kecord,  vol.  iv.  p.  82  ; 
Krombein,  Buffalo  Med.  and  Surg.  Journal,  June,  1864;  also  epidemic  in 


906  MEDICAL   DIAGNOSIS. 

that  our  hogs  are  not  infested.  On  the  contrary,  the  report  of  the 
Chicago  Academy  shows  that  about  1  in  50  contains  trichinae  in 
the  muscles.*  Our  comparative  immunity  from  the  affection  is 
due  to  the  pork  being  much  more  generally  cooked  thoroughly 
before  it  is  eaten ;  for  the  only  prophylactic  is  thorough  cook- 
ing, prolonged  exposure  to  high  temperature  killing  the  trichinae. 
Pickling  has  little  if  any  effect.  Salting  and  smoking  are  pre- 
ventive means  of  some  value,  but  do  not  insure  safety. 

Iowa,  Med.  and  Surg.  Eep.,  July  14,  1866,  and  Kistine,  Med.  Record,  1866, 
vol.  i.  p.  249;  Buck,  ib.,  1869,  vol.  iv.  ;  Hun,  Trans.  New  York  State  Medi- 
cal Society,  1869 ;  Sutton,  Trans.  Indiana  State  Medical  Society,  1875 ; 
Wendt,  Amer.  Journ.  Med.  Sci.,  April,  1878;  Barton,  College  and  Clinical 
Eecord,  Nov.  15,  1880. 

*  Chicago  Medical  Examiner,  May,  1866;  quoted  in  Medical  and  Surgical 
Reporter,  June  2,  1866. 


INDEX. 


A. 

Abdomen,  abscess  in  walls  of. 517 

auscultation  of 448 

diseases  of 440 

general  enlargement  of. 593 

inflammation  of  muscles  of, 
confounded  -with  perito- 
nitis   507 

inspection  of 441 

palpation  of 442 

percussion  of 443 

tumors  of 601 

Abscess,  bepatic 567 

lumbar,  confounded  with  aneu- 
rism   617 

of  abdominal  walls  confounded 

with  peritonitis 507 

of    brain    distinguished    from 

softening 177 

distinguished  from  tumor....  180 

of  kidney 701 

of  larynx 211 

of  liver 554,  567 

of  thoracic  walls   confounded 

with  chronic  pleurisy 333 

perinephritic 702 

peritoneal 613 

perityphlitic 515 

psoas,  confounded  with  aneu- 
rism   617 

confounded  with    csecal   ab- 
scess   517 

pulmonary,    confounded    with 

phthisis 295 

retropharyngeal 211,  436 

confounded  with  croup 211 

Acidity  of  stomach  as  a  symptom  451 

Acne... 859 

Acute  diseases  presenting  pain  in 

cardiac  region 369 

Addison's  disease 726 

confounded  with  fever-hues 729 

with  other  diseases  of  supra- 
renal capsules 730 


Addison's      disease     confounded 

with  phthisis 729 

confounded  with  vagrants'  dis- 
ease    729 

^Egophony 248 

.zEsthesiom  eter 62 

Albumen  in  the  urine 656 

Albuminuria,  simple,  confounded 

with  Bri2jht:3  disease 680 

Alcoholism 7 121,  880 

Alvine  discharges 484 

Amphoric  voice 243 

Anaemia 725 

cerebral 177 

confounded  with  Bright's  dis- 
ease    687 

progressive  pernicious 730 

retinal 74 

spinal 98 

Anaesthesia 59 

from  disease 59 

from  poisoning 59 

hysterical 105 

in  affections  of  nervous  centres.  60 

localized 60 

muscular 63 

trigeminal 61 ,  189 

Anaesthetics,  employment  of,   in 

feigned  aphonia 215 

Anasarca 715 

Aneurism,  abdominal 614 

intracranial 182 

of  abdominal  aorta  confounded 

with  aortic  pulsation 616 

with  colic 497 

with  disease  of  the  spine 616 

with  lumbar  and  psoas  ab- 
scess    617 

with  neuralgia 616 

with  non-aneurismal  pulsa- 
ting tumors 617 

with  rheumatism 616 

of  aorta  confounded  with  chro- 
nic laryngitis 213 

of  ascending  aorta 412 

907 


908 


INDEX. 


Aneurism  of  descending  aorta...  421 

of  innominate  artery 422 

of  pulmonary  artery 422 

thoracic 411 

Angina  pectoris 359 

simple  acute 426 

ulcero-membranous. 431 

Animal  parasites 889 

Ankle  clonus 84 

Anthrax 885 

Aorta,  aneurism  of  abdominal...  614 

aneurism  of  thoracic 414 

confounded  with  laryngitis...  213 

inflammation  of 375 

pulsation  of. 614 

Apepsia 450 

Aphasia 153 

Aphonia,  feigned 215 

nervous,  confounded  with  chro- 
nic laryngitis 213 

of  hysteria 213 

Aphthae 213 

Apoplexy 143 

attended  with  paralysis 144 

cerebellar 145 

confounded  with  acute  soften- 
ing    150 

with  aphasia 153 

with  asphyxia 149 

with  catalepsy 158 

with  cerebral  hysteria 152 

with  epilepsy 147,  160 

with  insensibility  from  drink  148 
with  insensibility  from  nar- 
cotics  148,  874 

with  meningitis 148 

with  obstruction  of  the  cere- 
bral arteries 151 

with  protracted  sleep 152 

with  sudden  paralysis 150 

with  sun-stroke 156 

with  syncope 149 

with  tumors 148 

with  uraemic  coma 149 

hemorrhage  a  cause  of 146 

pulmonary 310 

mistaken    for    acute    pneu- 
monia   310 

serous 145 

spinal 96 

Appendix  cseci,  diseases  of 513 

Appetite,  loss  of,  as  a  symptom...  449 

Arcus  senilis 398 

Arteries,  cerebral,  obstructions 
of,  confounded  with  apo- 
plexy   151 

inflammation  of  coats  of,  412, 

748,  756 

Ascaris  lumbricoides 890 

Ascites 593 


Ascites  confounded  with  cancer 

of  peritoneum 598 

confounded  with  chronic  peri- 
tonitis    597 

with  chronic  tympanitis 599 

with  distention  of  the  blad- 
der   599 

with  gravid  uterus 599 

with  ovarian  dropsy 595 

Asphyxia  distinguished  from  apo- 
plexy   149 

Asthma 254 

cardiac 257 

diagnosticated  from  dyspnoea..  256 

from  pressure  of  tumors 256 

hay 271 

Ataxia,  progressive  locomotor. ...   117 

Athetosis 167 

Atrophy  of  liver,  acute  yellow...  561 

chronic 593 

of  optic  nerve 74 

of  spinal  cord 101 

progressive  muscular Ill 

Auscultation 234,  250 

cerebral 1 32 

immediate 234 

mediate 234 

of  abdominal  viscera .  448 

of  children 252 

of  the  voice 248 

B. 

Bell's  palsy 108 

Beriberi 116 

Bile  in  the  urine 649 

Biliary  acid 649 

passages,  inflammation  of 560 

Bladder,   distended,   confounded 

with  ascites 599 

confounded  with  peritonitis..  506 

inflammation  of 699 

confounded  with  peritonitis..  506 
spasm    of,     confounded     with 

colic 494 

Blood,  diseases  of 720 

Blood-globule  counting 721 

Body,  position  of,  as  a  symptom..     30' 

Bowels,  hemorrhage  from 539 

morbid  discharges  from 531 

Brain,  abscess  of 177 

and  spinal  cord,  table  of  dis- 
orders of 128 

congestion  of. 176 

diseases  of 52 

headache  as  a  symptom  of...     65 
ophthalmoscopic     symptoms 

of 65 

dropsy  of 184 


INDEX. 


909 


Brain,  hardening  of. 178 

hemorrhage  into 176 

hypertrophy  of. 185 

distinguished  from  dropsy  of 

brain 185 

distinguished  from  enlarge- 
ment of  the  head. 185 

inflammation  of 179 

confounded  with  pericarditis  382 

lesions  of  gray  central  ganglia.  89 

localization  of  function  of 88 

meningitis  of  base  of 135 

softening  of 176 

table  of  diseases  of. 128 

tumor  of 179 

Brain-power,  exhaustion  of. 178 

Brass-founders'  ague 884 

Breathing,  condition  of,  in  laryn- 
geal diseases 194 

See  also  Respiration. 

Breath  sound,  metamorphosing...  243 

Bright's  disease,  acute .-677 

confounded   with  acute   ne- 
phritis    679 

with  coma 682 

with  convulsions 682 

with  dropsy 682 

with  hematuria 680 

with  pericarditis 681 

with  pleurisy 681 

with  pulmonary  oedema...  687 

with  purulent  urine 680 

with  simple  albuminuria..  680 
with  suppurative  nephri- 
tis   680 

chronic 683 

confounded  with  anaemia 687 

with  asthma 689 

with  cancer 690 

with  cardiac  dropsy 689 

with  chronic  bronchitis 688 

with  chronic  rheumatism..  688 

with  cysts  of  kidney 690 

with  gastro-intestinal  dis- 
orders    689 

with  neuralgia 688 

with  tubercle 690 

nervous  symptoms  in 682,  688 

retinitis  in 71 

table    of    clinical    differences 

in 696 

Bronchial    glands,    tuberculiza- 
tion of 260 

phthisis 260 

Bronchitis,  acute 266 

diagnosticated    from    capil- 
lary bronchitis 268 

from  hooping-cough 259 

physical  signs  of 262 

sputa  in 261 


Bronchitis,  capillary 268,  269 

confounded      with      lobular 

pneumonia 269 

chronic 270 

chronic,       confounded       with 

Bright's  disease 688 

with  nasal  catarrh 271 

with  phthisis 287 

sputa  in 261 

plastic 272 

Bronchophony 242 

Broncho-pneumonia 269 

Bronchorrhcea 270 

Bullous  diseases 858 


C. 


Caecum,  affections  of. 513 

appendix  of,  diseases  of. 513 

cancer  of. 516 

distention  of 516 

inflammation  of. 513 

Calculi,  renal 676 

Cancer  of  caecum 516 

of  gall-bladder 579 

of  intestine 613 

of    kidney     confounded    with 

Bright's  disease 690 

of  liver 574 

confounded  with  acute  con- 
gestion    577 

with  acute  hepatitis 577 

with  cancer  of  omentum..  580 

with  cancer  of  stomach 580 

with  chronic  congestion...  577 
with  disease  of  gall-blad- 
der   579 

with  enlarged  kidney 581 

with  fatty  liver 576 

with  syphilitic  liver 578 

with  waxy  liver 576 

oflungs 292 

confounded      with      chronic 

pleurisy 335 

with  phthisis....... 292 

of  lymphatic  glands 737 

of  lymphatic  glands  lying  by 

side  of  vertebrae 610,  616 

of  omentum  confounded  with 

cancer  of  liver 580 

of  peritoneum 612,  613 

of  stomach 476 

confounded  with   cancer   of 

liver 592 

with  chronic  gastritis. .471,  479 

with  gastric  ulcer 472,  479 

Carditis 385 

Catalepsy  accompanying  hysteria  158 
confounded  with  apoplexy 159 


910 


INDEX. 


Catalepsy   confounded   -with   ec- 
stasy    159 

daymare  form  of. 159 

Catarrh,  gastric 471 

nasal 271 

su ffocati ve 263 

Cavernous  voice 249 

Cerebellum,  diseases  of. 120 

Cerebral  affections 129 

pain  in,  distinguished  from 

hemicrania 189 

Cerebritis  confounded  with  men- 
ingitis    131 

Cerebro-spinal  disorders 119 

fever 794 

confounded  with  congestive 

fever 798 

with  inflammation  of  cord.  798 

with  pneumonia 799 

with  rheumatism 799 

with  scarlatina 799 

with      sporadic      cerebro- 
spinal meningitis 798 

with  tetanus 798 

with     tubercular     menin- 
gitis   798 

with  typhoid  fever 797 

with  typhus  fever 800 

with  uraemia 799 

Charcot's  disease 122 

Chest,  alterations  of  form,  size, 

etc.,  of,  in  disease 222 

dilatation  of,  diseases  present- 
ing   322 

diseases  of 218 

mapping  out  of,   for  phvsical 

diagnosis 220 

motions  of,  in  diseases  of. 221 

retraction  of.  diseases  attended 

with 335 

Cheyne-Stokes  respiration. ...258,  393 

Chicken-pox 845 

Childbed  fever 511 

Children,  auscultation  of. 252 

respiration  in : 251 

Chlorides  in  the  urine 642 

Chlorosis 726 

Choked  disk 73 

Cholera 544 

infantum 541 

morbus 543 

Chorea 164 

attended  with  salaam  convul- 
sions    168 

distinguished  from  athetosis 167 

from  convulsive  tremor 166 

from  epilepsy 166 

from  facial  spasm 167 

from  mercurial  tremor 167 

from  paralysis  agitans 166 


Chorea  distinguished  from  tetanus  166 

from  writer's  cramp 167 

post-paralytic 91 

relations  of,  to  rheumatism 166 

Choroid  coat,  inflammation  of 75 

tubercles  of 75 

Chylous    fluid    discharged    from 

leg 865 

Circulation,  derangements  of,  in 

cardiac  disease 357 

paralysis     from     interference 

with 78 

Cirrhosis  of  liver 586 

of  liver  confounded  with  can- 
cer of  stomach 592 

confounded  with  chronic  per- 
itonitis   591 

hy pertroph ic 589 

of  lung  confounded  with  chro- 
nic pleurisy 336 

Clots,  fibrinous,  in  the  heart..374.  744 

Coffee-ground  vomit 458,  478 

Colic...". 486 

as  a  symptom 487 

bilious 488 

confounded     with     abdominal 

aneurism 497,  615 

with  abdominal  neuralgia 496 

with  enteritis 497 

with  gall-stones 492 

with  gastralgia 491 

with  hernia 492 

with  nephralgia 493 

with  perforation  of  the  intes- 
tine   491 

with  peritonitis 497 

with  spasm  of  the  bladder...  494 

with  spinal  disease 497 

with  tumors 497 

with  uterine  colic 511 

flatulent 488 

lead 489 

metallic 489 

nervous 489 

spasmodic 487 

uterine 495 

Collapse  of  the  lung 275 

confounded     with     chronic 

pleurisy 357 

Colon,  dilatation  of 613 

Coma 56 

occurring  in  Bright's  disease...  682 

uramiic 131,  682 

Congestion    of    brain,    discrimi- 
nated from  softening 176 

pulmonary 309 

Congestive  fever 818 

Consciousness,   diseases    marked 

by  sudden  loss  of. 143 

Constipation  as  a  symptom 529 


IXDEX. 


911 


Constipation,  habitual 529 

Consumption.     See  Phthisis. 

galloping 301 

Convulsions 123 

See  also  Spasms. 

diseases  marked  by 159 

distinguished  from  epilepsy 163 

in  Bright's  disease 682 

salaam 168 

Cord.     See  Spinal  Cord. 

Cough 258 

in  laryngeal  affections 212 

Countenance,  expression  of,  as  a 

symptom 31 

Crackling  in  tubercle  of  lungs...  216 

Cramp  of  stomach 461 

writers 167 

Crepitation 245 

Croup 205 

catarrh al 205 

confounded    with     abscess     of 

larynx 211 

with  diphtheria 209 

with  laryngitis 210 

with     retropharyngeal     ab- 
scesses   211 

diseases  confounded  with 208 

false 205 

membranous,  confounded  with 

diphtheria = 210,  432 

spasm  of  glottis  in. 206 

true 207 

Cystitis,  acute 699 

chronic 700 

confounded  with  peritonitis....  506 
Cysts  of  kidney 691 


D. 

Daymare 159 

Debility  confounded  with  typhoid 

fever 781 

Delirium 53 

accompanying  insomnia 57 

active 53 

confounded  with  delirium  tre- 
mens    140 

feigned 55 

hysterical 55 

mistaken  for  insanity 54 

of  inanition 54 

passive 53 

prominent  as  a  symptom,  acute 

affections  with 129 

tremens 139 

confounded  with  acute  mania  142 

with  meningitis 140 

Dengue 846 

Diabetes 707 


Diagnosis  by  exclusion 23 

differential 22 

methods  of  arriving  at 21 

physical 221 

sources  of  error  in 24 

Diaphragm 257 

fatty  degeneration  of 258 

inflammation  of 257 

paralysis  of 257 

rheumatism  of 257 

Diarrhrea 532 

acute 532 

bilious 532 

choleraic 544 

chronic 533 

fatty 540 

intermittent ". 535 

membranous 536 

of  soldiers 534 

strumous 535 

tubercular 535 

Dilatation,  bronchial,  confounded 

with  phthisis 294 

of  heart 390 

confounded  with  fatty  degen- 
eration  .". 392 

confounded  with  pericardial 

effusion 390 

Diphtheria 428 

confounded  with  croup 210,  432 

with  erysipelas  of  the  fauces  431 
with  gangrene  of  the  mouth..  431 
with  pharvngitis  and  tonsil- 
litis   430 

with  scarlatina 433 

with  ulcerative  stomatitis....  430 
with  ulcero-membranous  an- 
gina   431 

intercurrent 434 

laryngeal 433 

nasal 434 

paralysis  in 106 

Discharges,  alvine 484 

as  a  symptom 484 

Displacements  of  heart 410 

Diuresis,  chronic 710 

Drink,  insensibility  from 148 

Dropsy 715 

abdominal 593 

acute 719 

cardiac 356,  719 

chronic 719 

hepatic 718 

of  brain 185 

ovarian 595 

pericardial 392 

confounded  with  cardiac  dil- 
atation   392 

renal 717 

Duodenum,  ulcer  of 476 


912 


INDEX. 


Dynamometer 80 

Dysentery 536 

acute 536 

chronic 538 

Dyspepsia  as  a  symptom 465 

Dysphagia 439 

Dyspnoea 253,  258 

diagnosticated  from  asthma 256 


E. 

Echin ococci 893 

Ecstasy 159 

distinguished  from  catalepsy...  159 

Ecthyma 860 

Eczema 856 

Effusions,  pericardial 395 

pleural 317,  328 

Electricity  in  paralysis 80 

Elephantiasis 864 

Emaciation  as  a  symptom 31 

Embolism 374,  742 

of  cerebral  arteries 151,  746 

of  pulmonary  artery 740 

Emphysema.. .." 272 

and  tubercle 286 

confounded  with  chronic  pleu- 
risy   330 

diagnosticated    from    pneumo- 
thorax   323 

interlobular 275 

Empyema,  pulsating,  confounded 

with  aneurism 416 

Endocardial  murmurs 370,  371 

Endocarditis,  acute 370 

confounded  with  pericarditis  380 

ulcerative 375 

Engorgements,  pulmonary,  in  fe- 
vers   309 

mistaken    for    acute    pneu- 
monia    309 

Enteritis 497 

acute 497 

confounded  with  colic 498,  499 

with  peritonitis 505 

with  typhoid  fever 782 

muco- 499 

Epigastrium,  tumors  of. 604 

Epiglottis,  swelling  of,  as  a  diag- 
nostic sign 215 

Epilepsy 159 

aura  preceding 160 

cardiac 362 

central  or  centric 161 

distinguished  from  apoplexy...  163 

from  chorea 166 

from  convulsions 163 

from  hysteria 168 

eccentric 161 


Epilepsy,  feigned 163 

followed  by  hemiplegia 161 

idiopathic 162 

of  retina 74 

peripheral 161 

sequelae  of. 161 

symptomatic 161 

syphilitic 162 

vertigo  previous  to 68 

Epistaxis 263 

Eructation  as  a  symptom 452 

Erysipelas 846 

confounded  with  mumps 847 

migrans 849 

of  the  fauces  confounded  with 

diphtheria 402 

Erythema 848,  853 

i ntertrigo 854 

Examination  of  patients,  methods 

of 27 

analytical 27 

synthetical 27 

Exanthematous  fevers 832 

Eye,  appearance  of,  in  disease 69 

condition  of  pupil  of,  in  cere- 
bral disease 70 


F. 


Face,  spasm  of 189 

Facial  paralysis 108 

Faecal  discharges 484 

Faeces,  accumulation  of. 603 

Farcy,   acute,   confounded   with 

pyaemia 739 

Fatty  degeneration  of  heart 392 

confounded  with  dilatation..  393 

Fauces,  diseases  of. 426 

erysipelas  of. 431 

inflammation  of 426 

pseudomembranous  inflamma- 
tion of 426 

ulcers  of 435 

Favus 867 

Feigned  aphonia 215 

delirium 53 

diseases 23 

epilepsy 163 

hysteria 168 

rheumatism 760 

sciatica 191 

Fever,  catarrhal 771 

cerebro-spinal 794 

Chickahominy 823 

congestive 818 

enteric 773 

hectic 808 

hemorrhagic  malarial 820 

infantile  remittent 817 


IXDEX. 


913 


Fever,  intermittent 806 

miasmatic 806 

nervous 777 

pharyngeal 849 

relapsing 801 

remittent 810 

scarlet 832 

simple  continued 770 

spotted 794 

syphilitic 809 

typhoid 773 

typho-malarial 813.  823 

t vphus 785 

urethral 809 

yellow 826 

Fevers 768 

classification  of 770 

continued 770 

head-symptoms  of,  confound- 
ed with  meningitis 132 

eruptive 832 

exanthematous 832 

periodical 806 

Fibrin,  clots  of,  in  the  heart 374 

Fifth  nerve,  painful  anesthesia  of  188 

Fire-measles 840 

Flatulency  as  a  symptom 452 

Follicular  pharyngitis 227 

Foot  and  mouth  disease 886 

Fremitus,  friction 227 

rhonchal 227 

vocal 227 

Friction,  pericardial 354 

pleural 246 

Fungus  foot  of  India  889 


G. 

Gall-bladder,    diseases    of,    con- 
founded   with    cancer    of 

liver 579 

inflammation  of 559 

Gall-ducts,  inflammation  of 559 

Gall-stones,  passage  of,  confound- 
ed with  cancer  of  the  liver  580 

with  colic 492 

with  fecal  accumulations 493 

with  intermittent  fever 808 

Gangrene  associated  with  paraly- 
sis      78 

pulmonary,    confounded    with 

phthisis  297 

Gastralgia 461 

confounded  with  colic 491 

Gastritis,  acute 466 

chronic 471 

confounded  with  gastric  can- 
cer   472 

with  gastric  ulcer 477 


Gastritis,     chronic,     confounded 

with  peritonitis 505 

of  young  children 469 

Gastrodynia 461 

confounded  with  colic 491 

Gastro-intestinal  disorders  con- 
founded with  Bright's  dis- 
ease   689 

German  measles 840 

Glanders,  acute,  confounded  with 

pyemia 739 

Glottis,  oedema  of. 205 

spasm  of 206 

Glycosuria 708 

Goitre,  exophthalmic 366 

Gout 760 

rheumatic 762 

Guinea-worm 894 


H. 

Hematemesis 457 

Hematocele,  periuterine 611 

Hematoma 147 

Hematuria 662 

intermittent 663,  821 

malarial 821 

renal 662 

vesical 622,  664 

Hemoptysis 262 

Hardening  of  the  brain 178 

distinguished  from  softening...  178 
Head,   enlargement   of,   diseases 

characterized  by 184 

shapes  of,  in  disease 186 

Headache 64 

from  astigmatism 64 

from  poisoning 66 

in  diseases  of  the  brain 65 

nervous 65 

neuralgia 65 

sympathetic 66 

uremic 688 

Hearing,  sense  of,  derangement  of    75 
Heart,  anatomv  and  phvsiology 

of T...  339 

aneurism  of 421 

atrophy  of 395 

auscultation  of 346 

chronic    diseases    of,    with   in- 
creased percussion  dulness  386 

clots  of  fibrin  in 373 

dilatation  of 390 

diseases  of 339 

symptoms  of 356 

displacements  of 410 

dropsy  caused  by  disease  of. 356 

fatty  degeneration  of 392 

functional  disorders  of 363,  398 


58 


914 


INDEX. 


Heart,  gouty 380 

hypertrophy  of 368,  386 

inflammation  of 385 

inspection  of 342 

irregularity  of  action  of 364 

irritable 367 

malformations  of 397 

organic  diseases  of. 369 

palpation  of 343 

percussion  dulness  of,  increased  386 

percussion  of 344 

physical  diagnosis 342 

rupture  of 394,  415 

strain 368 

valvular  affections  of 397 

Heart-burn 451 

Hemicrania 189 

distinguished  from  pain  of  or- 
ganic cerebral  aflections...  190 

from  peritonitis 190 

from  rheumatism  of  the  scalp  190 

Hemiplegia 85 

anatomical  diagnosis  of 87 

appearance  of  muscles  in 91 

cerebral 86 

cortical 89 

electricity  as  a  test  of 87,  91 

feigned 91 

following  epilepsy 161 

nature  of  lesions  in 90 

pathological  diagnosis  of 90 

right-sided,  associated  with  loss 

of  articulate  language 155 

scat  of  lesion  in 86 

spinal 87 

Hemorrhage  a  cause  of  apoplexy  143 
between  the  membranes  of  the 

brain 147 

cerebell  ar 146 

cerebral 147 

from  aneurism 264 

from  the  bladder 664 

from  the  kidneys 662 

from  the  larynx,  trachea,  etc...  264 

from  the  lungs 264 

from  the  oesophagus 263 

from  the  stomach 263,  475 

from  ventricles  of  brain 146 

in  apoplexy,  seat  of 146 

into  the  subarachnoid  spaces...   147 

of  the  bowels 539 

relations  of,  to  softening  of  the 

brai  n 176 

Hemorrhagic  malarial  fever 820 

confounded    with    intermit- 
tent hematuria 821 

with  yellow  fever 822 

Hepatic    diseases,    chronic    and 

acute,  confounded 555 

Hepatitis,  acute 554 


Hepatitis,  acute,  confounded  with 
acute  non-hepatic  dis- 
eases   557 

with  acute  yellow  atrophy  558 

with  cancer  of  liver 574 

with  chronic  hepatic  dis- 
ease with  acute  symp- 
toms   557 

with  diaphragmatic  pleu- 
risy   558 

with  inflammation  of  the 

biliary  passages 558 

with  inflammation  of  the 

portal  veins 555 

with  perihepatitis 555 

with  pigment  liver 556 

chronic 566 

interstitial 589 

Hernia,  diaphragmatic,  con- 
founded with  pneumo- 
thorax   327 

strangulated,  confounded  with 

colic 492 

with  intestinal  obstruction...  521 

Herpes 858 

Hiccough  in  diaphragmatic  pleu- 
risy    558 

Hip-joint   aflections    confounded 

with  sciatica 192 

Hodgkin's  disease 737 

confounded     with     lymphatic 

cancer 73 7 

Hooping-cough 259 

diagnosticated  from  bronchitis  260 

Hydatids  of  the  liver 568 

Hydrocephaloid  disease 137 

Hvdrocephalus,  acute 136 

chronic 136,  184 

Hydronephrosis 706 

Hydrophobia    confounded    with 

tetanus 174 

Hydrothorax    confounded     with 

chronic  pleurisy 334 

Hyperesthesia 57 

general 58 

hysteria  as  a  cause  of 58 

one-sided 59 

relations  of,  to  inflammation...     58 

Hypertrophy  of  brain 185 

enlargement    of    head    con- 
founded with 185 

of  heart 386 

of  skin 864 

Hypochondrium,  tumors  of.. .601,  602 
Hypogastric  region,  tumors  of.....  612 

Hysteria 168 

abdominal,     confounded    with 

peritonitis 510 

as  a  cause  of  hyperesthesia 58 

associated  with  catalepsy 158 


INDEX. 


915 


Hysteria,  cerebral,  distinguished 

from  apoplexy 152 

distinguished  from  chorea 166 

from  epilepsy 169 

feigned 171 

Hysterical  complaints,  local 170 

delirium 55 

hydrophobia 174 

locomotor  ataxia 121 

paralysis 76 

pseud  o-maladies 170 

tetanus 172 

Hy  stero-epilepsy 169 

I. 

Ichthyosis 862 

Icterus 548 

catarrhalis 559 

neon atorum 551 

Iliac  fossa,  diseases  attended  with 

pain  in 513 

region,  tumor  of 610 

Impetigo 860 

Inflammation,  local,  confounded 

with  neuralgia 186 

Influenza 772 

Innominate,  aneurism  of 422 

Inosi te 655 

Insanity  confounded  with  delir- 
ium       54 

Insensibility  from  drink  distin- 
guished from  apoplexy 142 

from    narcotics     distinguished 

from  apoplexy 142 

Insomnia 57 

with  delirium 57 

Inspection  in  diagnosis 221 

Insufficiency    of    aortic     valves 
confounded     with      aneu- 

•  rism 415 

Intellection,  deranged 52 

Intermittent  fever 806 

Intestines,  cancer  of 613 

disease  of 484 

inflammation  of 497 

intussusception  of 524 

invagination  of. 517,  524 

obstruction  of 519 

percussion  of. 443 

perforation      of,      confounded 

with  colic 491 

Intoxication,  ursemic 682 

Itch 866 

army 866 

J. 

Jaundice 548 

of  the  new-born 551 


K. 

Kakke 116 

Kidney,  abscess  around 702 

abscess  of 701 

cancer  of 690 

contracted 695 

cysts  of 690 

enlarged,  chronically  inflamed    693 
confounded   with    cancer   of 

liver 581 

with  ovarian  tumor 611 

fatty 692 

hydatids  of 707 

inflammation  of. 672 

pelvis  of 704 

movable 609 

neuralgia  of 673 

pain  in 678 

confounded  with  colic 489 

percussion  of. 446 

suppurative  inflammation  of...  701 

tubercle  of 690,  707 

tumors  of 517 

waxy 694 

Kreati  n  e 644 

Kreatinine 644 

L. 

Laryngeal  affections,  acute 202 

stenosis 216 

stridor 194 

Laryngismus  stridulus 207 

Laryngitis,  acute 202 

confounded  with  croup 204 

chronic 212 

aneurism  of  aorta  confounded 

with 213 

combined  with  syphilis 213 

with  tuberculosis 213 

confounded      with      altered 

voice 214 

with  aneurism 419 

with  hysterical  aphonia....  213 

with  nervous  aphonia 213 

diffuse  cellular 204 

diseases  confounded  with 213 

feigned 215 

secondary,  of  the  exanthemata.  210 

spasmodic 209 

stridulous 207 

Laryngoscopy 195 

Larynx,  abscess  of. 211 

acute  diseases  of 202 

affections  of  nerves  of 213 

changes    in  breathing  in    dis- 
eases of 194 

in  voice  in  diseases  of 194 


916 


INDEX. 


Larynx,  chronic  diseases  of. 212 

cough  in  diseases  of 195 

discuses  of. 194 

inflammation  of 204 

organic  diseases  of 202 

pain  in  diseases  of 195 

stenosis  of 216 

table  of  diseases  of. 202 

tumors  of 216 

Lead-poisoning 882 

paralysis  from 105,  883 

Lepra 861 

Leucine 647 

Leucocythssmia 7:;4 

Leukaemia 734 

pseudo-leukaemia  distinguished 

from 737 

Lichen 855 

ruber 855 

scrofulosorum 855 

Lithaemia 762 

Liver,  abscess  of 567 

acute  affections  of,  confounded 

with  pyaemia 740 

congestion  of 553 

confounded  with  cancer  of 

liver 577 

inflammation  of 555 

yellow  atrophy  of 558 

cancer  of. 574 

chronic  atrophy  of 592 

congestion  of 563 

confounded  with  cancer  of 

liver 578 

inflammation  of 566 

cirrhosis  of. 58G 

enlargement     of,     confounded 

with  chronic  pleurisy 335 

fatty 572 

confounded    with    cancer   of 

liver 577 

fibro-fatty 589 

hydatids  of. 582 

movable 609 

percussion  of 445 

pigment,      confounded      with 

acute  hepatitis 556 

red  atrophy  of 591 

simple  induration  of 590 

syphilitic,     confounded     with 

cancer  of  liver 578 

table  of  diseases  of 552 

torpor  of 565 

waxy 573 

confounded    with   cancer    of 

liver 577 

Locomotor  ataxia 117 

of  syphilitic  origin 121 

Lu  mbago 758 

Lumbar  region,  tumors  of. 609 


Lungs,    acute    affections    of,    in 

typhoid  fever 784 

confounded  with  tubercular 

meningitis 135 

cirrhosis  of 336 

collapse  of. 275 

diseases  of 221 

fistulous  opening  into 337 

oedema  of 309,  681 

scrofulous  disease  of 300 

symptoms  of  diseases  of 253 

syphilitic  disease  of 293 

Lung-tissue,  detection  of 279 

Lupus 863 

Lymphadenoma 737 

distinguished   from   lymphatic 
cancer 737 

M. 

Maculae 862 

Malaria,  poisoning  by 816,  822 

Malarial  cachexia..... 816,822 

Malformations  of  heart 397 

confounded  with  valvular  af- 
fections   397 

Malignant  pustule 885 

Mania,  acute 142 

confounded  with  meningitis.  142 

with  delirium  tremens 142 

Measles 837 

confounded  with  scarlet  fever..  836 

with  smallpox 843 

Ger ma n 840 

Memory,  disordered,  as  a  symp- 
tom    52 

Meniere's  disease 67,  566 

Meningitis,  acute 129 

confounded  with  acute  mania  142 

with  apoplexy 148 

with  eerebritis 131 

with  delirium  tremens 140 

with    head-symptoms    of 

acute  rheumatism 134 

of  continued  fevers 132 

of  pericarditis 134 

of  pneumonia 134 

with  typhoid  fever 783 

ccrebro-spinal 139,  724 

confounded  with  myelitis....  139 

diseases  confounded  with 139 

chronic,  distinguished  from  tu- 
mor   180 

of  the  base  of  the  brain 135 

spinal 98 

tubercular 134 

diseases  confounded  with 135 

Mensuration  of  chest 222 

Men tair ra 867 


INDEX. 


917 


Mental  faculties,  diseases  charac- 
terized by  gradual  impair- 
ment of. 175 

Mercurial  tremor 882 

Metritis  confounded  with  peri- 
tonitis   505 

Milk-leg  confounded  with  acute 

rheumatism 753 

Milk-sickness 887 

Molluscum 868 

Monoplegia 92 

br  achio-faci  al 92 

crural 93 

oculo-motor 93 

Motion,  deranged 76 

voluntary,  diseases  marked  by 

sudden  loss  of 143 

Mouth,  diseases  of. 423 

Mumps 427,  829 

Murmur,  respiratory 238 

vesicular 237 

absence  of. 239 

causes  of 237 

changes  in 237 

Murmurs,  cardiac 350 

dynamic 398 

endocardial 350 

functional  valvular...; 398 

hsemic 398 

pericardial 354 

without  valvular  lesion 398,  409 

Muscse  volitantes 69 

Muscles,  appearance  of,  in  par- 
alysis      80 

morbid  states  of,  paralysis  from     78 
Muscular  movements,   irregular 

forms  of 120 

Myalgia 759 

Myelitis 99 

central .' 100 

disseminated 100 

hemorrhagic 100 

tran  sverse 100 

Myocarditis 385 


N. 

Narcotics,  insensibility  from 148 

poisoning  by 874 

Nausea  as  a  symptom 452 

Nephralgia...". 672 

confounded  with  colic 493 

Nephritis 671 

acute,   confounded  with  acute 

Bright's  disease 679 

interstitial 698 

suppurative 680 

Nephrophthisis 691 

Nerves,  diseases  of. 52 


Nerves,  paralysis  from  affections 

of. 76 

Nervous  affections,  classification 

of 128 

deranged  nutrition   and  se- 
cretion in 125 

centres,  diseases  of,  anaesthesia 

a  symptom  of 59 

paralysis  from 77 

system,  diseases  of 52 

Neuralgia 186 

as  a  cause  of  headache 64 

cerebral 189 

confounded  with  aneurism 615 

with  local  inflammation 187 

with  pain  of  rheumatism 187 

epileptiform 189 

facial 188 

in  Bright's  disease 688 

intercostal 188 

confounded  with  acute  pleu- 
risy   321 

lumbo-abdominal 496 

of  bladder 494 

of    spinal    nerves    confounded 

with  colic 497 

of  stomach 496 

ovarian 493 

reflex 187 

Neuritis,  acute  progressive 97 

optic 72 

Nutrition,  deranged 125 

O. 

(Edema 716 

of  the  glottis 204 

diagnosticated  from  croup...  210 

of  trichiniasis 813 

pulmonary 309 

mistaken  for  acute  pneumo- 
nia   309 

occurring  in  Bright's  disease  681 

(Esophagus,  dilatation  of. 438 

inflammation  of. 437 

stricture  of. 437 

Omentum,  cancer  of 580 

Ophthalmoscope  in  diseases  of  the 

nervous  system 71 

Opisthotonos 171 

Opium-poisoning 874,  879 

Optic  neuritis 72 

tract,  diseases  of 90 

Orthopncea 254 

Ovarian  dropsy  confounded  with 

ascites 595 

inflammation 495 

neuralgia 496 

Oxalate  of  lime  in  the  urine 645 

Oxaluria 645 


918 


INDEX. 


P. 

Pain  as  a  symptom 43 

cardiac 358 

gastric,  as  a  symptom 460 

in  diseases  of  the  liver 548 

paroxysmal,  diseases  character- 
ized by 186 

Palpation  of  the  chest 227 

Palpitation 362 

cardiac,  diseases  attended  with  364 
Palsy.     See  Paralysis. 

Bell's 108 

shaking 122,  166 

wasting 11 1 

Pancreas,  diseases  of. (104 

Papular  diseases 855 

Paralysis 76 

acute  anterior  spinal 115 

acute  ascending 96 

agitans 122,  166,  183 

distinguished  from  chorea...  166 

from  general  paralysis 183 

associated  with  gangrene 78 

clinical  investigations  of 70 

creeping 77 

diphtheritic 10G 

electro-muscular    contractility 

in 80 

essential 114 

facial 108 

from  affection  of  nerves  at  their 

extremities 77 

from  apoplexy 144 

from  chronic  softening 175 

from  interference  with  the  cir- 
culation   78 

from  lead-poisoning 78,  105 

from  lesion  of  nervous  centres..  77 

in  the  course  of  a  nerve 77 

from  locomotor  ataxia 117 

from  morbid  state  of  the  mus- 
cles    78 

from  poisoning 78 

from      progressive      muscular 

atrophy Ill 

from  reflex  action 77,    97 

general 76,  182 

confounded  with  softening...  182 
distinguished  from  other  pal- 
sies   183 

glosso-laryngeal 110 

glosso-pharyngeal 110 

glossoplegic 93 

hysterical 76,  104 

intermitting 78 

local 108 

malarial 78 

of  radial  nerve Id'.) 

partial 76 


Paralysis,  peripheral 77 

pseudo-hypertrophic  muscular  115 

rheumatic 105 

spastic  spinal 102 

sudden,  distinguished  from  apo- 
plexy   95 

syphilitic 106 

tabular  view  of 116 

Paraplegia 94 

from  various  diseases 96 

gradual 97 

reflex 103 

seat  of  lesion  in 95 

spinal 97,  116 

sudden 95 

varieties  of. 96,  146 

Parasites 888 

animal 889 

vegetable 888 

Paresis,  spinal 96 

Parotitis 427 

See  also  Mumps. 

Patella  tendon  reflex 84 

Pectoriloquy 243 

Pemphigus 858 

Percussion 227 

auscultatory 231 

clearness    of,    as    a   diagnostic 

sign 265 

dulness    of,   diseases   accompa- 
nied by 277 

immediate 234 

mediate 227 

of  abdominal  viscera 443 

of  healthy  chest 232 

respiratory 231 

sounds  elicited  by 228 

Perforation,  intestinal,  confound- 
ed with  colic 491 

Periarteriitis  nodosa 905 

Pericarditis,  acute 376 

diagnosticated  from  endocardi- 
tis   380 

from  gastric  irritation 382 

from  inflammation  of  brain..  382 

from  pleuritis 381 

friction  sounds  of 378 

head-symptoms  of,  confounded 

with  meningitis 134 

in  Bright's  disease 687 

Pericardium,  dropsy  of 392 

effusion    of,    confounded    with 

chronic  pleurisy 331,  387 

Perihepatitis 555 

Perinephritis 702 

Peritoneum,  diseases  of 484 

Peritonitis,  acute 500 

confounded  with  abdominal 

hysteria 510 

with  colic 511 


INDEX. 


919 


Peritonitis,     acute,     confounded 

with  cystitis..." 506 

with  distention  of  bladder..  506 

with  enteritis 505 

with  gastritis 505 

with  inflammation  and  ab- 
scess of  abdominal  mus- 
cles   507 

with  metritis 505 

with  rheumatism  of  ab- 
dominal walls 509 

with  typhoid  fever 710 

chronic '. 511 

confounded  with  ascites 553 

local 504 

puerperal 502 

Perityphlitis 478,  515 

Pernicious  anaemia 730 

confounded  with  Addison's  dis- 
ease   730 

with  chlorosis 733 

with  contracted  kidney 732 

with  disease  of  heart 733 

with  disease  of  stomach 732 

with  leukaemia 734 

Phantom  tumors 606 

Pharyngitis     confounded     with 

diphtheria 430 

Pharynx  and  oesophagus,  diseases 

of 436 

Phlegmasia  dolens 716 

confounded  with  rheumatism..  753 

Phosphates  in  the  urine 639 

Phthisis 277 

acute 301 

bronchial 260 

chronic  pneumonic 288 

confounded  with  bronchial  dila- 
tation   294 

with  bronchial  phthisis 261 

with  chronic  bronchitis 287 

with  chronic  pleurisy 292 

with  chronic  pneumonia 289 

with  emphysema 287 

with  pulmonary  abscess 295 

with  pulmonary  cancer 292 

with  pulmonary  gangrene...  297 

fibroid 336 

laryngeal 216 

temperature  in 280 

Physical  diagnosis 221 

Pigment  liver 556 

Pityriasis  versicolor 867 

Plague  confounded  with  typhus..  793 

Pleura,  cancer  of 335 

effusion  into 334,  337 

fistula  of , 337 

Pleurisy,  acute 316 

confounded  with  acute  pneu- 
monia    320 


Pleurisy,  acute,  confounded  with 

intercostal  neuralgia 322 

with  pericarditis 333,  387 

with  pleurodynia 321 

bilious 315 

chronic 328,  335 

confounded   with  abscess  in 

thoracic  walls 333 

with  cancer 331 

with    chronic    pneumonic 

consolidation 336 

with  cirrhosis 336 

with  collapse  of  lung 337 

with  emphysema 330 

with  enlargement  of  liver.  332 
with  enlargement  of  spleen  333 

with  hydrothorax 334 

with  intra-thoracic  tumor..  331 
with  pericardial  effusion...  333 

with  phthisis 292 

with  pneumothorax 330 

with  tubercle 334 

diseases  confounded  with 330 

circumscribed 332 

diaphragmatic,         confounded 

with  acute  hepatitis 558 

double 292 

Pleurodynia 321 

confounded  with  acute  pleurisy  322 

Pneumo-hydro-pericardium 384 

Pneumonia 305 

acute 305 

confounded  with  acute  pleu- 
risy    320 

with  bilious  pneumonia 315 

with  pulmonary  apoplexy.  310 
with  pulmonary  engorge- 
ment in  fevers 309 

with  pulmonary  cedema...  309 
with  typhoid  pneumonia..  313 
head-symptoms       of,      con- 
founded with  meningitis  134 

auscultation  in 306 

bilious 315 

catarrhal 269,  312 

chronic,  confounded  with  chro- 
nic pleurisy 336 

confounded  with  phthisis 289 

chronic  catarrhal 291 

lobular 312 

mistaken  for  bronchitis 312 

malarial 315 

typhoid 313 

Pneumothorax 325 

diagnosticated    from     chronic 

pleurisy 326 

from  diaphragmatic  hernia...  327 

from  emphysema 323 

Poisoning,  acute 870 

alcohol 875,  880 


920 


LNDEX. 


Poisoning,  aniline 

arsenic 873, 

benzine 

Calabar  bean 

carbolic  acid 

chloral 

chloroform 

chronic 

copper 

ergot 874, 

followed  by  coma 

fungi 

lead 

malarial 810,  818, 

mercurial 

narcotic 

insensibility  from,  con- 
founded with  apoplexy 

ni  trobenzole 

opium 874, 

petroleum 

phosphorus 

picrotoxin 

producing  anaesthesia 

headache 

paralysis 

prussic  acid 

strychnia 

confounded  with  tetanus. .173, 

sulphuret  of  carbon 

tobacco 

zinc 

Poisons 

animal 

irritant 

Poliomyel  itis 

Portal  veins,  inflammation  of, 
confounded  with  acute 
hepatitis 

inflammation  of,  with  coagula. 

Position  as  a  symptom 

Prurigo 

Pruritus 

Pseudo-leukaemia 

Pseudo-tabes  mesenterica 450, 

Psoriasis 

Pulsation,  abdominal 

aortic 

confounded  with  aneurism  of 

abdominal  aorta 

Pulse,  condition  of,  in  disease.... 

dicrotic 

irregular 

respiration-ratio,  perverted 

slow 

study  of,  as  a  symptom 

Purging,  diseases  attended  by.... 
Purpura 

hemorrhagica 

rheumat  ica 


870 
884 
875 
878 
870 
ST.", 
875 
879 
884 
881 
56 
874 
882 
823 
882 
874 

875 
140 
879 


59 
64 

76 
876 


884 
881 
885 
870 
885 
871 
115 


555 
591 
30 
853 
869 
736 
607 
861 
614 
614 

617 

34 

37 

35 

305 

35 

34 

531 

750 

750 

750 


Purulent  urine 665 

diseases  associated  with 699 

Pya-mia 738 

arter i  al 740 

chron  ic 741 

confounded    with    acute  affec- 
tions of  liver 740 

with  acute  glanders 739 

with  intermittent  fever 808 

with  rheumatic  fever 739 

with  typhoid  fever 739 

spontaneous  septic 741 

Pyelitis 704 

catarrhal 705 

Py oneph rosis 706 


Q. 

Quinoidine,  animal,  in  malaria...  877 
Quinsy 426 

R. 

Rachitis 185 

Radial  nerve,  paralysis  of 109 

Rales 244 

Records  of  cases,  plans  for 29 

Reflex  excitability 83 

abdominal 85 

cremaster 85 

epigastric 85 

tendon 84 

Regions  of  chest 220 

Relapsing  fever 801 

confounded  with  typhoid  and 

typhus  fever 804 

Remittent  fever 810 

infantile 817 

Respiration,  amphoric 243 

bronchial 241 

cavernous 242 

feeble 238 

harsh 241 

in  children,  peculiarities  of 251 

jerkins; 240 

metallic 243 

prolonged 240 

puerile 238 

sounds  of,  in  health 236 

supplementary 237 

vesiculobronchial 24 1 

Respiratory  movements 221 

percussion 231 

Retinitis 71 

albuminuric 72 

syphilitic 72 

Retropharyngeal  abscesses 436 

Rheumatic  gout 762 


INDEX. 


921 


Rheumatic  paralysis 102 

Rheumatism 752 

acute 752 

confounded  with  acute  syno- 
vitis   753 

with  milk-leg 753 

with  trichiniasis 903 

head  -  symptoms      of,      con- 
founded with  meningitis  756 

heart-symptoms  in 756 

chronic 757 

confounded  with  abdominal 

aneurism 617 

with  Bright's  disease 688 

with  neuralgia 187 

with  sciatica 192 

feigned 760 

gonorrhceal 754 

muscular 757 

confounded  with  trichiniasis  903 

of  abdominal  walls 509 

periosteal 760 

relations  of,  to  chorea 165 

subacute 757 

Rheumatoid  arthritis 762 

Rhinoscopy 197 

Rhonchi 244 

Rhythm  of  respiration,  changes 

in 237 

Rickets 764 

craniotabes  confounded  with...  766 
hereditary  syphilis  confounded 

with 766 

mollities    ossium    confounded 

with 766 

Rigidity,  local,  confounded  with 

tetanus 172 

Rose  cold 271 

Roseola 854 

Rubeola 840 

notha 839 

Rupia 860 

S. 

Salaam  convulsions 168 

Salivation 423 

Sarcinse  ventriculi 455 

Scabies 866 

Scalp,  rheumatism  of,  confounded 

with  hemicrania 190 

Scarlatina 832 

confounded  with  diphtheria....  433 

with  smallpox 843 

Sciatica 191 

distinguished  from  hip-joint  af- 
fections   192 

from  irritation  of  the  kidney  192 

from  rheumatism 192 


Sciatica,  feigned 192 

pressure  of  fluid  on  nerve  in...  192 

rheumatic 192 

Sclerema 864 

Sclerosis,  cerebro-spinal 122,  183 

lateral  amyotrophic 102 

of  antero-lateral  columns 101 

posterior 118 

spinal 100 

Scrofula,  pulmonary 299 

and  tubercle 300 

Scurvy 748 

confounded  with  purpura 750 

Seborrhoea 868 

Sensation,  deranged 125 

impaired 57 

perverted 57 

Sensations  of  patients 43 

Senses,  special,  derangement  of...     69 

Septicaemia 741 

Skin,  condition  of,  as  a  symptom     33 

diseases 851 

altered  gland  secretions 868 

bullous 858 

classification  of 852 

erythematous 853 

hypertrophies 864 

maculae 862 

nervous 869 

new  growths 863 

papular 855 

parasitic 865 

pustular 859 

squamous 860 

syphilitic 869 

vesicular 856 

Sleep,   protracted,   distinguished 

from  apoplexy 152 

Smallpox 841 

confounded  with  measles 843 

with  scarlet  fever 843 

Softening  of  the  brain 175 

acute,     distinguished     from 

apoplexy 150 

chronic 175 

discriminated  from  abscess  177 

from  congestion 176 

from       exhaustion       of 

brain-power 178 

from  hardening 178 

from  tumor 179 

paralysis  from 176 

red 175 

relations  of,  to  hemorrhage..  176 

white ."...  175 

of  spinal  cord 101 

Sore  throat 426 

chronic 435 

clergyman's 435 

Sound,  bronchial 241 


922 


INDEX. 


Sound  elicited  by  percussion 232 

Hippocratic  or  succussion 227 

in  chest,  adventitious 243 

tubular 242 

Spasm,  bronchial 254 

facial 189 

distinguished  from  chorea....  167 

masticatory,  of  the  face 173 

of    bladder    confounded    with 

colic 511 

of  glottis  in  croup 206 

Spasms 123 

See  also  Convulsions. 

clonic 123 

diseases  marked  by 159 

saltatory 125 

tonic 124 

Sphygmograph 37 

Spinal  cord,  atrophy  of 97 

congestion  of 97 

diseases  of 95 

hemorrhage  into 96 

inflammation  of 99 

morbid   conditions   of,    as   a 

cause  of  paraplegia 94 

sclerosis  of 101 

softening  of 100 

tumors  of 103 

tumors  pressing  on 103 

paresis 96 

Spine,    disease    of,     confounded 

with  aneurism 616 

disease    of,    confounded    with 

colic 497 

Spirometer 225 

Spleen,  affections  of 602,  784 

displacement  of ♦..  608 

enlargement     of,     confounded 

with  chronic  pleurisy 333 

percussion  of 445 

Spotted  fever 794 

Sputa 261 

nummular 278 

of  acute  pneumonia 305 

of   bronchitis 262 

of  phthisis 278 

Stetho-goniometer 223 

Stethometer  of  Quain 225 

Stethoscope 234,  235 

application   of,  to  larynx  and 

trachea 195 

Stomach,  acidity  of,  as  a  symp- 
tom    451 

acute  diseases  of 466 

inflammation  of 466 

cancer  of 476 

catarrh  of 468 

chronic  affections  of 470 

cramp  of 461 

dilatation  of 482 


Stomach,  diseases  of 449 

fibroid  thickening  of 482 

gout  in 694 

hemorrhage  from 457 

inspection  of 442 

irritation  of,  confounded  with 

pericarditis 382 

neuralgia  of 462 

palpation  of 442 

percussion  of 443 

softening  of. 469 

ulcer  of 472 

Stomatitis 430 

ulcerative,    confounded     with 

diphtheria 431 

Stools  as  symptoms 484 

Strabismus 69 

Stricture  of  the  oesophagus 437 

Stridor,  laryngeal 194 

Strych ma-poisoning 878 

confounded  with  tetanus.  173,  878 

St  u  por 55 

in  uraemia 683 

St.  Yitus's  dance.     See  Chorea. 

Sugar  in  the  urine 650 

tests  for 651 

Sulphates  in  the  urine,  pathology 

of 643 

test  for 644 

Sun-stroke 156 

distinguished  from  apoplexy...  156 

Supra-renal  capsules,  disease  of...  726 

Surface  thermometry 44 

Sweating,  excessive 127 

Sycosis 867 

Symptoms,  disguised 25 

'feigned 23 

pathognomonic 21 

similarity  of,  in  diseases 25 

study  of 26 

Syncope  distinguished  from  apo- 
plexy   149 

Synovitis,  acute,  confounded  with 

acute  rheumatism 753 

Svphilis   combined    with    laryn- 
gitis   213 

Syphilitic  diseases  of  the  liver....  578 

of  the  lungs 293 

of  the  skin 869 

fever 809 

ulcers 436 

T. 

Tabes  dorsalis 118 

mesenterica 607 

pseudo-mesenterica 450,  607 

Tactile  sense,  impairment  of. 62 

Tape- worm 891 


INDEX. 


923 


Temperature  of  tody  as  a  symp- 
tom       44 

cerebral '. 46,  93 

in  apoplexy 103 

in  cancer 51 

in  cerebro-spinal  fever 796 

in  intermittent  fever 807 

in  measles 843 

in  phthisis 280,  305 

in  pyaemia 738 

in  relapsing  fever 804 

in  remittent  fever 811 

in  scarlatina 843 

in  smallpox 843 

in  trichiniasis 901 

in  typhoid  fever 775 

in  typhus  fever 787 

of  surface 44 

Tenderness  as  a  symptom 44 

Tetanus 171 

confounded  with  hydrophobia..  174 

with  local  rigidity 173 

with  spasms  in  scarlet  fever  173 
with       strychnia  -poison- 

ing 173,  878 

distinguished  from  chorea 166 

hysterical 172 

idiopathic 171 

intermittent 173 

symptomatic 172 

traumatic 171 

Thermometer,  clinical  use  of.. ..44,  47 
See  also  Temperature. 

Thermometry,  general 47 

surface 44 

cerebral 202 

Thermoscope 46 

Thirst  as  a  symptom 451 

Thoracic  aneurism ." 412 

confounded  with  chronic  laryn- 
gitis  i 419 

with  dilated  auricle 416 

with  insufficient  aortic  valves  415 
with    malformation    of   the 

chest 417 

with  malposition  of  the  aorta  418 

with  morbid  growths 414 

with  pulsating  empyema 416 

with  pulsation  of  pulmonary 

arterv 417 

Thrombosis" 712,  742 

of  brain  sinuses 181 

of  cerebral  arteries 151 

Thrush 424 

Tic  douloureux 58 

Tinnitus  aurium 75 

Tongue,  condition  of,  in  disease..     40 

inflammation  of 425 

Tonsillitis 426 

confounded  with  diphtheria....  430 


Torticollis 759 

Trachea,  affections  of. 194,  218 

symptoms  of  diseases  of 195 

Tremor 121 

convulsive 166 

mercurial,  distinguished  from 

chorea 167 

Trichina  spiralis 895 

Trichiniasis 896 

Trismus 171 

Tube-casts  in  the  urine 692,  694 

Tubercle 277 

and  scrofula 300 

calcareous  transformation  of...  299 
confounded  with  chronic  pleu- 
risy   292 

Tubercular  meningitis 134 

eye-changes  in 75 

Tuberculization      of      bronchial 

glands 260 

Tuberculosis  of  lungs 277 

See  also  Phthisis. 

acute  miliary 302 

combined  with  laryngitis. .214,  216 
confounded  with  Bright's  dis- 
ease    690 

Tumors,  abdominal 601 

confounded  with  colic 497 

cerebral 179 

distinguished  from  apoplexy  148 

from  softening 179 

intra-thoracic,  confounded 

with  chronic  pleurisy 332 

mediastinal. 414 

non-aneurismal,       confounded 

with  abdominal  aneurism  617 

of  larynx.... 216 

of  spinal  cord 103 

ovarian 610 

phantom 606 

Tympanites,  chronic 600 

confounded  Avith  ascites 600 

Typhlitis 513 

Typhoid   conditions    confounded 

with  typhoid  fever 781 

Typhoid  fever  confounded  with 

cerebro-spinal  fever 797 

with  enteritis 782 

with  general  debility 781 

with  meningitis 783 

with  peritonitis 783 

with  pulmonary  affections...  784 

with  remittent  fever 813 

with  trichiniasis 902 

with  typhoid  conditions 781 

with  typhus  fever 792 

epistaxis  in 779 

eruption  in 779 

spinal  symptoms  in 778 

Typho-malarial  fever 823 


924 


INDEX. 


Typhus  fever 785 

and  typhoid  fever,  differential 

diagnosis  of 792 

cerebral  Bymptoma  in 788 

confounded  with  plague 794 

Ty rosi  ne 647 


U. 

Ulcer  of  duodenum,  corrosive....  4 70 

gastric 473 

confounded  with  chronic  gas- 
tritis   479 

with  gastric  cancer 47' ' 

with  ulcer  of  duodenum...  476 

Umbilical  region,  tumors  of 607 

Urajmia 682 

distinguished  from  ammonise- 

mia 684 

Uremic  coma  distinguished  from 

apoplexy 149 

Urates,  pathology  of 637 

tests  for 638 

Urea,  pathology  of. 630 

table  for  estimation  of  daily  ex- 
cretion of,  from  the  specific 

gravity... 634 

tests  for...' 601 

Uric  acid  in  gout 761 

detection  of. 761 

pathology  of 635 

Urinarv  organs,  diseases  of... 019,  670 

Urine 619 

abnormal  constituents  of 645 

acid  free  in 629 

albuminous  conditions  of. 076 

alkaline 629 

analysis  of 622 

bloody 

changes  in  constituents  of. 630 

chylous 667 

color  of,  changes  in 623 

estimate  of  solids  in 627 

increased  discharge  of. 707 

pigment  in 624 

test  for 625 

pus  in 61  15 

quantitative  examination  of...  621 

reaction 628 

retention  of 713 

sediments 669 

specific  gravity  of 627 

suppression  of 717 

table  showing  action  of   tests 

upon 669 

Urticaria 8-54 

Uterus,  colic  of,  confounded  with 

ordinary  colic 189 

gravid,  confounded  with  ascites  599 


V. 


Vagrants'  disease 729 

Valvular  affections  of  the  heart..  396 
confounded     with     functional 

cardiac  disease 398 

with  malformations  of  heart  397 
with  misdirection  of  current  398 
development  of,  from  rupture 

of  a  valvulet 410 

table  of 405 

Variola 841 

Varioloid 845 

Veins,  portal,  inflammation  of...  548 

Vertigo 66 

aud  i  tory 67 

from  overwork 68 

1  a  ry  ngeal 68 

precursor  of  epilepsy 68 

stomachal 66 

Viscera,    abdominal,    percussion 

and  auscultation  of 443 

Vision,  derangement  of 69 

V oca  1  fremitus 249 

resonance 249 

Voice,  altered,  with  or  without 

chronic  laryngitis 212 

amphoric 249 

auscultation  of 248 

cavernous 248 

changes  in,   in   laryngeal  dis- 
eases     194 

Vomit,  cottve-ground 458,  478 

different  forms  of 453 

Vomiting  as  a  symptom 401' 

diseases  accompanied  by. ...466,  541 

faecal 456 

in  brain  diseases 475 

W. 

Water-brash 456 

"Womb,    inflammation    of,    con- 
founded with  peritonitis...  502 

Wool-sorters'  disease 886 

Worms,  intestinal 890 

Writer's  cramp 167 

Wry- neck 759 

Y. 

Yellow  fever 826 

confounded      with      remittent 

fever 830 

diseases  confounded  with 829 

Z. 

Zinc-poisoning 884 


COLUMBIA   UNIVERSITY 

This  book   is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C2B  6381MSO 

